HX64117863 
RC61  .Z1  Clinical  lectures  de 


RECAP 


Columbia  ^nibtr<sitt|) 
uitljtaTitpoti^ttogork 


^^tUvmtt  Htbrarg 


v^ott  =:j 


G.    A.    ZACHARIN. 


CLINICAL  LECTURES 


DELIVERED  BEFORE  THE  STUDENTS 


OF    THE 


IMPERIAL  MOSCOW  UNIVERSITY 


BY 

G.   A.   ZACHARIN,   M.D. 

Late  Professor  cEaieritus)  of  Clinical  Medicine  and  Director  of  the  Therapeutical 

Faculty  Clinic  of  the  Imperial  Moscow  University,  Honorary  Member  of 

the  Imperial  Academy  of  Sciences  at  St.  Petersburg 


TRANSLATED  FROM  THE  FIFTH  RUSSIAN  EDITION 

BY 

ALEXANDER    ROVINSKY,    M.D. 

Member  of  the  Massachusetts  Medical  Society 


BOSTON 

DAMRELL    &    UPHAM 

1899 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/clinicallecturesOOzakh 


PREFACE. 


It  is  tlie  purpose  of  these  lectures  to  serve,  as  far  as  it  is  pos- 
sible to  do  so  in  print,  the  same  aims  as  are  pursued  by  clinical 
mstruction,  namely  :  by  proceeding  from  the  picture  of  the  mor- 
bid condition  as  it  presents  itself  in  the  patient  and  as  obtained 
by  interrogation,  physical  examination  and  from  the  collected 
data  concerning  his  past,  to  diagnosticate  this  morbid  state,  in 
whatever  peculiar  and  complex  form  it  may  appear,  to  prescribe 
a  plan  of  treatment  for  the  same,  and  to  execute  this  plan 
before  and  with  the  participation  of  the  students.  In  rela- 
tion to  these  last  and  to  the  practising  physician,  the  clinical 
lecture  is  also  intended  to  serve  as  a  specimen  of  methodical 
practical  activity,  "teaching  the  processes  of  interrogation, 
diagnosis,  treatment  and  observation  of  the  given  disease  or 
of  the  given  class  of  diseases."  Aiming  first  of  all  to  make 
of  his  students  practical  physicians,  the  clinical  instructor 
should  offer  to  the  future  practitioners  only  w^hat  is  essential, 
preeminently  practical  and  absolutely  requisite :  methods  of 
doubtful  utility,  whether  of  diagnosis  or  treatment,  unneces- 
sary superfluity  of  details  and  supposititious  theorizing,  have 
no  place  in  the  teaching  of  the  true,  conscientious  clinician. 
The  printed  clinical  lecture  is  distinguished  by  the  same 
characteristics. 

The  following  reasons  induced  the  author  to  devote  to  the 
first  case  a  much  greater  number  of  pages  (35—120)  than  to 
any  other:  being  the  first  case  presented,  it  required  ipso  facto 
a  detailed  circumstantial  analysis  — as  regards  both  diagnosis 
and  treatment  —  and  observation  to  the  very  end ;  it  was. 
moreover,  a  complex  case,  presenting  a  combination  of  various 
morbid  conditions  ;  further,  the  space  was  largely  devoted  to 
the    mmeral    waters,  a   subject   of  great   importance   in   thera- 


IT    

peutics,  which  is  unfortunately  very  little  appreciated  or 
even  entirely  neglected  in  the  United  States.  The  reader 
will  find  these  reasons  more  fully  explained  by  the  author 
in  his  "  Introduction  to  Clinical  Exercises." 

I  have  followed  the  author's  original  intention  (as  explained 
by  him  in  the  preface  to  the  Russian  edition)  of  omitting  to 
designate  at  the  head  of  each  lecture  the  particular  diagnosis 
of  the  disease  under  discussion.  This  is  but  in  conformity 
with  the  general  character  of  the  work,  which  aims  to  be  as 
like  a  lecture,  or  rather  a  demonstration,  in  the  clinic,  as 
possible.  Says  the  author  in  his  preface :  "  The  clinical  in- 
structor, on  presenting  a  patient  before  his  class,  does  not 
announce  the  diagnosis  of  the  morbid  affection  at  once,  but 
gradually  unfolds  it,  as  it  were,  in  an  evolutionary  manner. 
If  he  were  to  announce  the  diagnosis  at  the  beginning,  and 
then  proceed  to  examine  the  patient,  he  would  only  be  proving 
a  known  proposition,  instead  of  finding  the  unknown  ;  whereas 
his  students,  as  future  physicians,  will  always  have  to  find  the 
unknown,  which  will  demand  solution.  .  .  .  Moreover,  to  an- 
nounce the  diagnosis  beforehand,  thus  giving  the  solution  of 
the  problem,  would  deprive  the  student  of  that  mental  stimu- 
lus, which  spurs  him  on  to  seek  for  the  solution."  For  the 
convenience  of  the  reader  I  have  marked  the  diagnosis  of  the 
cases  in  the  list  of  contents,  and  have  compiled  an  index  of  the 
same. 

As  regards  the  method  of  examination  adopted  by  the 
author,  the  reader  will  find  a  detailed  description  of  it  in 
the  author's  Introduction.  It  is  only  necessary  for  me  to 
state  briefly  the  following :  with  the  great  progress  of  recent 
years  in  all  the  domains  of  the  healing  art,  the  various  and 
rapidly  increasmg  methods  of  what  is  known  as  physical  ex- 
amination have  driven  farther  and  farther  into  the  background 
the  individuality  of  the  patient  himself ;  we  are  threatened 
with  the  approach  of  a  period  in  medicine,  when  diseases  will 
be  treated  per  se,  as  such,  without  any  regard  to  the  charac- 
teristic peculiarities  of  the  patient  afilicted  by  them.  It  is 
a  well-known  fact,  that  one  and  the  same  disease  will  take 
on  different  forms  in  different  individuals,  all  departing  more 


or  less  from  the  type,  though  similar  to  it  in  the  essentials. 
It  is,  therefore,  necessary  to  become  acquainted  with  the  per- 
sonality of  the  patient  as  thoroughly  as  possible,  or,  in  other 
words,  we  must  individualize  each  and  every  case.  A  syste- 
matic examination  by  inquiry,  i.  e.  mterrogation  conducted  ac- 
cording to  a  certain  method,  is  the  only  means  that  will  enable 
us  to  obtain  a  true  and  reliable  insight  into  the  characteristic 
peculiarities  of  the  patient,  which  cannot  be  obtained  by  anj^ 
means  offered  to  us  by  the  so-called  physical  methods  of 
examination.  This  will  frequently  enable  us  to  distinctly  fix 
the  setiology  of  the  disease  (by  interrogating  the  patient  on 
his  condition  and  mode  of  living),  and  greatly  assist  in  arriving 
at  a  general  as  well  as  a  minutely  particular  diagnosis ;  it  will 
often  also  supply  us  with  valuable  material  for  treatment. 
This  method  of  interrogation,  which,  as  fulh'  worked  out  by 
the  author  in  his  Introduction,  was  highly  praised  (and  also 
adopted  by  many  prominent  clinical  teachers)  by  the  well- 
known  French  clinician  Henri  Huchard,*  is  by  no  means  a 
mechanical  putting  together  of  various  facts,  out  of  the  sum- 
mary of  which  a  sort  of  mathematical  deduction  is  made 
forming  the  diagnosis ;  it  is,  on  the  contrary,  "  an  active, 
searching  condition  of  mind " :  for  while  the  facts  are  being 
collected,  they  are  at  the  same  time  classified  in  the  interroga- 
tor's mind,  and  the  diagnosis  is  being  evolved,  so  that  by  the 
time  the  data  are  fully  collected,  the  diagnosis  either  formu- 
lates itself  in  the  mind,  or  is  easily  formulated.  It  is  true 
that  the  process  of  interrogating  the  patient  will  be  in  the 
beginnmg  somewhat  slow  and  laborious ;  however,  once  ac- 
quired, the  practitioner  will  need  but  little  time  for  mterrogat- 
ing  his  patient  in  as  thorough  a  manner  as  the  case  may  re- 
quire. He  will  also  soon  be  able  to  distinguish  from  among 
the  data  communicated  to  him  by  the  patient,  the  necessary 
from  the  superfluous  ones.  There  are,  moreover,  cases,  as 
those  of  neurasthenia,  hysteria,  and  the  like,  in  which  inter- 
rogation  is  the   only  means  by  the  aid  of  which   we  may  hope 

*  He  calls  the  chief  characteristic  of  Zacharin's  school  "  rinterroga- 
toire,  qui  ent  eleve  ()  I'hauteur  d'un  art  ''  (Expose  de  V Enaeignement  clinique, 
par  Zakharine,  Introduction  par  Henri    Huchard,  p.  3,  Paris,  1891). 


to  reach  any  diagnostic  conclusions,  for  in  these  affections 
physical  methods  of  examination  play  but  a  subordinate  role. 
It  is  at  the  same  time  self-understood  that  we  must  avoid 
extremes  in  either  relying  altogether  on  interrogation  to  the 
neglect  of  physical  methods  of  examination,  or  in  allowing 
these  last  to  entirely  overshadow  or  exclude  the  interrogatory 
examination;  a  judicious  combination  of  the  two  is  a  sine  qua 
non  of  a  successful  diagnosis  and  treatment. 


The  author  of  these  lectures,  Gregory  Antonovitch  Zacha- 
rin,  was  connected,  in  the  capacity  of  instructor  and  professor, 
with  the  Medical  Department  of  the  Imperial  Moscow  Univer- 
sity for  a  period  extending  over  thirty-five  years  (1861-1896).* 
A  man  of  indomitable  energy  and  very  pronounced  individu- 
ality, he  is  considered  as  the  founder  of  what  is  known  in  the 
Russian  medical  world  as  the  Zacharin  school  of  practical 
medicine  (we  touched  above  on  some  of  the  prominent  charac- 
teristics of  this  school),  in  whose  tenets  were  brought  up 
several  generations  of  physicians  scattered  in  every  nook  and 
corner  of  the  Great  Empire.  He  came  of  a  poor,  but  very  old 
family  of  nobility,  and  was  compelled  from  his  early  student- 
years  to  struggle  with  want  and  privation  ;  but  thanks  to  the 
possession  of  an  iron  will  and  unswerving  determination,  he 
rose  to  a  position  equal  to  that  occupied  by  Botkin  and  Piro- 
goff,  the  greatest  medical  minds  of  Russia.  It  may  be  truly 
said  that  Pirogoff,  Botkin  and  Zacharin  form  the  great  triad  of 
Russian  clinical  medicine  of  the  nineteenth  century. 

Zacharin's  most  pronounced  characteristic  trait  was  probably 
his  independence.  "  The  physician  should  be  independent, 
even  more  so  than  the  poet  or  the  artist,  for  to  him  we  entrust 
our  most  valuable  possession,  namely,  our  health,  our  very 
life  "  ;  and  for  the  practical  realization  of  this  ideal  he  struggled 
unremittingly  his  whole  life.  Being  a  leader  of  men,  his  stand 
has  greatly  contributed  to  the  elevation  of  the  name  and  the 
position  of  the  medical  profession  in  Russia.     To  form  an  ap- 

*  His  death,  which  occurred  January  5,  1898,  just  when  this  translation 
was  being  completed,  delayed  its  appeai'ance  until  now. 


proximate  idea  of  those  obstacles  which  Zacharin  had  to  over- 
come in  establishing  for  himself  and  for  his  calling  an  indepen- 
dent, respected  social  position,  it  will  suffice  to  introduce  here 
the  following  few  sentences  from  the  address  delivered  by  Prof. 
Sneguireff  at  the  Zacharin  Memorial  Meeting  of  the  Moscow 
Physio-Medical  Society : 

"  We  all  remember  the  time  when  the  physician  was  not 
allowed  to  sit  down  in  the  presence  of  his  social  superiors,  how 
some  of  us  were  only  allowed  to  treat  serfs  or  servants,  how 
others  served  on  the  gentlemen  and  the  ladies,  appearing  every 
morning  to  inquire  after  their  'graces"  health,  for  which  they 
were  paid  by  occasional  gifts  of  flour,  grain,  fowls,  etc, ;  a  phy- 
sician was  considered  as  an  accessory  to  the  rich  household, 
never  as  a  necessity,  and  his  labor,  advice  and  time  as  trifling 
and  superfluous." 

Zacharin  may  justly  be  called  a  public  hygienist,  for  he  first 
of  all  insisted,  and  very  rigidly  at  that,  on  the  necessary  changes 
in  the  patient's  mode  of  life  and  surroundings,  if  any  cure  was 
to  be  obtained  at  all.  In  this  regard  his  minute  and  precisely 
given  instructions  were  not  to  be  trifled  with,  and  "  Zacharin 
said  so  !  "  was  a  dictum  not  to  be  lightly  disobeyed  by  his  pa- 
tients, whom  he  always  took  the  trouble  to  personally  instruct 
minutely  in  individual  hygiene.  As  his  personal  practice  was 
very  extensive  and  his  followers  numerous,  we  can  easily  ap- 
preciate the  influence  of  such  instructions  on  the  health  of  so- 
ciety at  large. 

He  was  a  true  therapist  and  a  staunch  believer  in  remedial 
agencies  and  their  efficiency.  It  is  said,  that  at  his  death-bed, 
when  the  question  of  consultation  was  being  discussed  (he  died 
of  acute  bulbar  paralysis  caused  by  haemorrhage  into  the  me- 
dulla oblongata,  which  was  early  diagnosed  by  himself),  he  ob- 
served quietly,  but  firmly  :  "  Why  consultations  ?  Have  you 
not  done  all  in  your  power  ?  You  have  cleared  the  bowels,  ap- 
plied leeches  and  Spanish  flies,  and  administered  bromides : 
therapy  has  done  everything ;  the  rest  is  beyond  our  power." 

Although  laconic,  concise  and  precise  in  examining  a  pa- 
tient, he  would  sometimes  spend  two  or  even  three  hours  of 
closest  scrutiny  and   inquir3%  thus   forming   in  his  mind  a  per- 


fectly  clear  and  distinct  picture  of  the  patient's  condition  and 
Kis  surroundings,  and  thanks  to  his  phenomenal  memory  this 
picture  was  stored  up  in  his  mental  reservoir,  to  be  sometimes 
called  up  in  its  entirety  before  the  astonished  patient  after  five 
or  six  years,  thus  inducing  the  latter  to  repose  implicit  confi- 
dence in  his  knowledge  and  skill.  Besides  being  a  great  teacher 
(he  was  uninterruptedly  professor  at  the  University  until  1896, 
when  he  was  compelled  to  resign  for  reasons  into  which  we 
cannot  enter  here),  he  was  also  instrumental  in  assisting  the 
establishment  of  various  special  clinics,  and  especially  the  one 
in  gynaecology. 

He  was  the  attendant  physician  to  the  late  Emperor  Alexan- 
der III  in  his  fatal  illness  —  acute  interstitial  nephritis. 

Some  time  before  his  death  Zacharin  donated  one  quarter 
million  dollars  (one  half  million  roubles)  for  the  parochial 
schools  in  Russia. 

I  take  here  the  opportunity  to  express  my  gratitude  to  Mme. 
E.  P.  Zacharin  and  to  Prof.  N.  Th.  Golouboff,  of  the  Imperial 
Moscow  University,  whose  valuable  information  and  advice 
have  greatly  aided  me  in  my  work. 


These  lectures,  which  in  the  original  passed  through  five  edi- 
tions in  the  period  of  a  few  years,  were  partly  translated  into 
both  German  (^Klinisehe  Ahhandlungen :  iiber  den  klinischen  Un- 
terricht,  die  Oalomel-Therapie,  etc.  Von  Prof.  Dr.  G.  Sacharjin. 
Berlin,  1890,  August  Hirschwald;  and  KUnische  Vortrdge,  1892, 
same  publisher)  and  French  (^U Expose  de  V Enseignement  eli- 
nique,  par  Zakharine,  avec  une  Introduction  par  Henri  Huchard. 
Paris,  1891,  O.  Doin,  editeur;  and  Legons  cliniques  sur  les  Ma- 
ladies  ahdominales^  etc.,  traduit  de  la  deuxieme  edition  russe  par 
le  Dr.  Oelsnitz  (de  Nice),  1893.  Same  publisher,  also  preface 
by  H.  Huchard). 

Alexaintder  RovEsrsKY,  M.  D. 

Boston,  Mass.,  U.S.A.,  January,  1899. 


CONTENTS. 


Preface,  iii. 

INTRODUCTION^  TO  cli:nical  EXEECISES. 

(thkee  lecttjkes.) 

The  importance  of  the  clinic  in  medical  education,  1 ;  clinical  exercises  in 
their  relation  to  medical  education,  2  ;  the  necessary  requisites  of  clini- 
cal instruction  :  a  regular  method  and  a  system  of  individualization, 
3;  varieties  of  clinics  :  conforming  to  the  grades  of  medical  studies, 
3,  4;  by  their  contents;  the  general  clinic,  4:  the  character  of  its 
content  and  its  principal  aims,  5,  6;  the  scope  of  clinical  exercises.  6; 
examination  of  the  patient,  7;  examination  embraces  status  prsesens 
and  anamnesis,  8;  status  prsesens  consists  of  interrogation  and  objec- 
tive examination,  8,  9;  interrogation  about  the  patient's  mode  of  liv- 
ing, 9, 10 ;  interrogation  about  patient's  condition  conducted  according 
to  an  adopted  plan,  embracing :  appetite  and  thirst,  the  tongue,  teeth, 
etc.,  10;  circumstantial  inquiry  necessary  regarding  the  condition  of 
the  evacuations,  11 ;  the  anus ;  the  urinary  bladder,  male  genital  or- 
gans; history  of  syphilis,  and  so  on,  12-16;  Anamnesis,  also  parents' 
health,  17;  Objective  examination,  VJ ;  avoid  unnecessary  minuteness 
and  supei-fluity  of  details,  17,  18;  tact  a  requisite,  18;  Diagnosis:  how 
arrived  at,  18;  diagnosis  of  the  disease  (diagnosis  morbi),  of  the  pa- 
tient (diagnosis  segri),  and  differential  diagnosis  (diagnosis  per  exclu- 
sionem),  19;  Prognosis:  its  importance  in  the  hospital  as  compared 
with  that  in  private  practice,  19;  as  regards  the  i^atient,  20,  21 ;  as  re- 
gards the  patient's  relatives,  21;  conciseness  in  wording  a  prognosis: 
not  serious,  serious,  dangerous  and  hopeless,  22;  Treatment :  method 
and  a  system  of  individualization  necessary,  22;  therapeutic  nihilism 
and  undue  enthusiasm  for  certain  drugs;  neglect  of  hygienic  treat- 
ment, 23;  simultaneous  emj)loyment  of  many  drugs  to  be  avoided, 
24;  characteristics  of  hospital  therapy,  2.5;  observations  of  the  course 
of  the  malady,  26;  the  making  up  of  deficiencies  in  the  students''  knowl- 
edge, 26;  importance  of  autopsies,  27;  the  importance  of  the  clinic  in 
scientific  medicine,  27,  28;  the  duties  of  the  clinical  instructor:  dis- 
eases taken  up  in  order  for  clinical  instruction,  28,  29 ;  participation 
of  students  in  the  clinical  exercises,  26,  30;  duties  of  clinical  assist- 
ants, :30 ;  business  of  students:  to  conduct  the  history  of  the  disease, 
and  the  description  of  the  same;  service  in  the  clinic,  30,  31. 


CLINICAL   LECTURES. 

ABDOMINAL   DISEASES  AND   FUNCTIONAL   DISTURBANCES   OF 

THE  NERVOUS  SYSTEM.  —  THE  INTERNAL   USE  OF 

MINERAL   WATERS. 

FiKST  Case. — Chronic  gastro-intestinal  catarrh,  biliary  calculi,  renal 
colic,  oxaluria,  probably  movable  kidney,  Kseconclary  nervous  disturb- 
ances, etc.,  35-121. 

Anamnesis,  40,  41 ;  Course  of  disease,  37-40,  45,  55,  66,  81,  97,  117, 
120,  121 ;  Diagnosis,  55-5S,  60,  67-69,  70,  72;  Diet,  37,  74,  75,  78,  81,  98; 
Hygiene,  43,  73,  74;  Mode  of  living,  35,  36;  Objective  examination,  45- 
49;    Prognosis,  73;   Treatment,  37,  45,  50-54,  67,  78-80,  82,  98,  117-120. 

The  internal  use  of  mineral  waters:  sodium  bicarbonate  and 
chloride  in  various  catarrhal  conditions,  86;  the  unreplaceability  of 
the  natural  mineral  waters  by  artificial  ones,  87;  the  use  of  mineral 
waters  at  every  season  of  the  year,  83;  the  action  of  the  curative 
agencies  of  the  mineral  waters:  water,  carbonic  acid,  bicarbonate  and 
chloride  of  sodivim,  laxative  salts,  90-92. 

Table  of  mineral  watei'S,  93;  Ems,  94;  Franzensbad,  Kissingen, 
Karlsbad,  Vichy,  95;  Yessentucki,  Obersalzbrunnen,  96,  97;  Marien- 
bad,  95,  99-101 ;  compared  to  Ems,  101 ;  compared  to  Vichy,  102  ;  to  Kis- 
singen, 103;  to  Karlsbad,  102-104;  Franzensbad  Salzquelle,  104;  indica- 
tions for  Vichy,  104,  105;  for  Yessentucki,  105;  Contrex(^ville,  97,  106. 

The  reliability  of  the  combinations  of  remedial  agencies,  as  con- 
tained in  the  mineral  waters,  107;  the  routine  method  of  drinking 
the  waters  at  the  resorts,  109,  110;  the  quantity  of  the  daily  dose  de- 
pending on  the  effect  desired  —  Ems,  Obersalzbrunnen,  Vichy,  111, 
112;  Yessentucki  and  Karlsbad,  112,  113;  Marienbad,  Kissingen,  113; 
the  length  of  the  coarse  of  treatment,  113,  114;  the  distribution  of 
the  quantity  of  the  water  over  the  course  of  the  day,  114;  as  regards 
meals,  114,  115;  indications  for  cold  and  warm  waters,  115;  the  diet 
while  drinking  the  waters,  115,  116;  contraindications  to  the  use  of 
waters,  116,  117. 

Second  Case.  — Clironic  gastric  catarrh,  gastric  ulcer,  nervous  dyspepsia, 
dilatation  of  the  stomach,  122-138. 

Anamnesis,  123,  124;  Course  of  the  disease,  125,  126,  138;  Diag- 
nosis, 127.  128;  differential,  129;  Diet,  124,  125,  138;  Mode  of  living, 
122,  123  ;  Objective  examination,  126,  127 ;  Prognosis,  130 ;  Treatment, 
124.  1:30-132. 

Gastric  lavage:  effects  of,  132,  133;  indications  for,  133;  not  an 
indifferent  procedure,  133;  mistaken  employment  of  lavage,  134;  typ- 
ical cases  in  which  it  fails,  134,  135  ;  wrongly  applied,  136,  137. 

Thikd  Case. — Nervous  dyspepsia,  139-155. 

Anamnesis,  139,  140 ;  Course  of  disease,  140-142,  144,  154,  155  ; 
Diagnosis,  143;  Diet,  142;  Hygiene,  145,  146:  Mode  of  living,  139;  Ob- 
jective examination,  141  ;  Prognosis,  144,  145 ;  Treatment,  140,  142, 
143,  14.5-149,  154,  1.55. 


Varieties  of  gastro-intestinal  disorders  in  neurasthenia,  149;  diet 
in  nei'vous  dyspepsia,  149,  150;  treatment  of  constipation,  152,  154; 
douclies,  massage,  etc.,  in  nervous  dyspepsia,  151;  drugs,  151,  152; 
the  various  laxatives,  152,  153 ;  clysters,  153,  154. 

FoTJKTH  Case.  —  Atrophic  gastric  catarrh,  cancer  of  the  duodenum,  156- 
161. 

Anamnesis  and  mode  of  living,  156,  157;  Autopsy,  160;  Course  of 
disease,  157,  158;  Diagnosis,  158;  differential,  159,  160;  Objective  ex- 
amination, 157;  Treatment,  158,  160. 

Fifth  Case.  —  Cancer  of  the  pancreas,  162-165. 

Anamnesis  and  mode  of  living,  162 ;  Autopsy,  165 ;  Course  of  dis- 
ease, 163,  165;  Diagnosis,  differential,  163,  164;  Prognosis,  164;  Treat- 
ment, 163,  164. 

Sixth  Case.  —  Biliary  calculi  and  cholangitis,  166-181. 

Anamnesis  and  mode  of  living,  166,  167;  Course  of  disease,  168, 
175,  177,  178;  Diagnosis,  168,  169,  171,  174;  Objective  examination, 
168;  Prognosis,  176;  Treatment,  167,  176-181. 

Biliary  calculi :  cause  of  formation,  169,  170,  176 ;  relation  to  neu- 
ralgia of  the  hepatic  plexus,  171,  173,  174  ;  differential  diagnosis,  172, 
173  ;  symptoms  aggravated  at  the  beginning  of  treatment  with  Karls- 
bad, 175  ;  duration  of  course  of  treatment,  179,  180. 

Seven^th  Case.  —  Hypertrophic  venous  cirrhosis  and  cholangitis,  182-192. 
Anamnesis  and  mode  of  living,  182,  183  ;  Course  of  disease,  183, 
184,  192  ;  Diagnosis,  185,  186 ;  differential,  187,  188,  190  ;  Objective  ex- 
amination, 184-186  ;  Prognosis,  191,  192  ;  Treatment,  183,  184,  191,  192. 
Hepatic  diseases:  differential  diagnostication  necessary,  187  ;  na- 
ture of  the  various  cirrhoses  of  the  liver,  188,  189  ;  clinical  data  con- 
cerning same,  189,  190. 

Eighth  Case.  —  Biliary   calculi,  cholangitis  and  slight  hypertrophic  bil- 
iary cirrhosis,  193-196. 

Anamnesis  and  mode  of  living,  193  ;  Course  of  disease,  193,  194, 
JL95  ;  Diagnosis,  194;  Objective  examination,  194;  Prognosis,  194; 
Treatment,  195.  196. 

Ninth  Case. — Echinococcus  cyst  of  the  liver,  slight  peritonitis,  197-201. 
Anamnesis  and  mode  of  living,  197,  198 ;  Course  of  disease,  198, 
200  ;  Diagnosis,  198,  199  ;  Objective  examination,  198  ;  Prognosis,  199  ; 
Treatment,  199,  200. 

Tenth  Case.  —Syphilis  of  the  liver,  202-208. 

Anamnesis  and  mode  of  living,  202  ;  Course  of  disease,  202,  203, 
206,  207,  208;  Diagnosis,  203,  204,  205;  Objective  examination,  203; 
Prognosis,  205  ;  Treatment,  205,  206,  208. 


RHEUMATISM   AND    GOUT. 
Eleventh  Case.  —  Acute  articular  rheumatism,  209-214. 

Anamnesis  and  mode  of  living,  207  ;  Course  of  disease,  209,  210, 
211,214;  Diagnosis,  210 ;  Prognosis,  210;  Treatment,  209.  210,  211,  212. 

Acute  articular  rheumatism  an  infectious  disease,  212  ;  its  rela- 
tion to  gout,  213,  214. 

Twelfth  Case.  —  Polyarthritis  chronica  (chronic  articular  rheumatism)' 
and  predisposition  to  gout,  215-224. 

Anamnesis  and  mode  of  living,  215 ;  Course  of  disease,  216,  221, 
223  ;  Diagnosis,  216,  217;  Prognosis,  222;  Treatment,  222,  223. 

The  inapplicability  of  the  term  chronic  articular  rheumatism, 
necessity  for  precise  nomenclature,  217-219 ;  nature  of  affections  em- 
braced under  the  current  name  of  chronic  rheumatism,  219,  220 ; 
change  of  term  recommended,  221. 

Thibteexth  Case. — ^Gout  (arthritis  urica),  224-230, 

Anamnesis  and  mode  of  living,  224,  225 ;  Course  of  disease,  225, 
226,229,230;  Diagnosis.  226 ;  differential,  227;  Prognosis,  227;  Treat- 
ment, 225,  226,  227,  228,  229,  230. 

Fourteenth  Case. — -Gout,  nephrolithiasis,  biliary  calculi,  fatty  liver, 
etc.,  231-236. 

Anamnesis  and  mode  of  living,  231,232;  Course  of  disease,  231, 
2132,  233,  234,  235,  236;  Diagnosis,  2:33,  234,  235;  Prognosis,  235;  Treat- 
ment, 235,  236. 

DISEASES   OF   THE   KIDNEYS. 
Fifteenth  and  Sixteenth  Cases,*  237-247. 

Fifteenth  Case. — -Chronic  interstitial  nephritis. 
Anamnesis  and  mode  of  living,  236;  Course  of  disease,  238,  247; 
Diagnosis,  244,  245:  Prognosis,  245;  Treatment,  246. 

Sixteenth  Case. — ^Parenchymatous  nephritis. 

Anamnesis  and  mode  of  living,  238,  239;  Course  of  disease,  239, 
240,  241,  242,  247;  Diagnosis,  245;  Prognosis,  245;  Treatment,  239, 
240,  246. 

Nature  of  chronic  nephritis,  242 ;  symptoms  of  the  interstitial  as 
compared  with  the  parenchymatous  variety,  242,  243;  prognosis  of 
either  variety,  243,  244;  course  of,  243,  244. 


ANiEMI^. 
SEVENTEE>fTH  Case.  —  Clilorosis,  248-257. 

Anamnesis  and  mode  of  living,  24S;  Course  of  disease,  248,  249; 
Diagnosis,  249;  differential,  249,  250;  Prognosis,  253,254;  Treatment, 
254-257. 

*  Erratum  on  p.  237  :    Should  be  fifteenth  and  Bixtoenth  cases,  instead  of  six- 
teenth and  seventeenth. 


Chlorosis :  unsatisfactory  classification  of,  in  the  text-books,  250, 
251 ;  the  nervous  system  in  relation  to  chlorosis,  251,  252;  sexual  ma- 
turity in  relation  to  chlorosis,  252 :  Brown-Sequard's  theory,  252;  hae- 
moglobin in  chlorosis,  253 ;  hysteria  and  chlorosis,  253 ;  iron  and  ar- 
senic in  chlorosis,  255,  256;  treatment  of  constipation  in  chlorosis, 
256 ;  of  the  nervous  system,  257. 

Eighteenth  Case.  • —  ChloranaBniia  and  inciijient  pulmonary  tuberculosis, 
258-262. 

Anamnesis  and  mode  of  living,  2.58,  259;  Course  of  disease,  2-59, 
262 ;  Diagnosis,  260,  261 ;  Objective  examination,  259 ;  Prognosis.  261 ; 
Treatment,  261,  262. 

THORACIC   AND    INFECTIOUS   DISEASES. 

Nii^ETEENTH  Case.  —  Tuberculous  pleurisy,  263-273. 

Anamnesis  and  mode  of  living,  263,264;  Course  of  disease,  264, 
270,271,272;  Diagnosis,  265,  236;  Objective  examination,  264;  Prog- 
nosis, 266 ;  Treatment,  264,  270,  271,  272,  273. 

Pleurisy:  Eichhorst's  treatment,  267;  author's  treatment,  267, 
268;  treatment  of  the  fever  with  antipyretics  and  with  calomel,  268, 
269;  to  further  absorption  of  exudations,  269,  270. 

Twentieth  and  Twenty- first  Cases,  27'4-283. 

Twentieth  Case.  —  Chronic  pulmonary  tuberculosis. 
Anamnesis  and  mode  of  living,  274,  275 ;   Course  of  disease.  275, 
276,  278,  281,  282;  Diagnosis,  277,  278,  280,  231 ;  Objective  examination, 
276;  Prognosis,  276 ;  Treatment,  275. 

Twenty-first  Case.  —  Chronic  tubercular  broncho-pneumonia  and 
chronic  bronchial  catarrh. 

Anamnesis  and  mode  of  living,  278,  279 ;  Course  of  disease,  279, 
230,  232,  283;  Diagnosis,  282;  Objective  examination,  280;  Prognosis, 
289 ;  Treatment,  279,  282,  283. 

How  the  invasion  of  the  lungs  by  tuberculosis  takes  i^lace,  277. 

GrSNEKAL  REMARKS  CONCEENING  THE  DIAGNOSIS  OF  CHRONIC  TUBER- 
CULOSIS OF  THE  Lungs,  283-290.  —  Varieties  of  chronic  tuberculosis 
and  their  complications,  284;  pulmonary  phthisis  as  compared  with 
incipient  tuberculosis,  285;  the  nature  and  cause  of  the  hectic  fever, 
2!i5,  286;  pneumoniae  complicating  chronic  pulmonary  tuberculosis: 
croupous,  286;  catarrhal  and  caseous,  287;  galloping  phthisis,  287, 
288:  acute  miliary  tuberculosis,  288;  peculiarities  in  the  course  of 
tuberculosis  depending  on  the  nature  of  the  organs  affected,  288. 
2S9;  prognosis  of  tuberculosis  pulnionum,  239,  290. 

Treatment  of  Chronic  Pulmonary  Tuberculosis,  200-298. 

Definition  of  a  speciJic  remedy,  291;  symptomatic  treatment: 
haemoptysis,  291,  292;  fever,  292;  employment  of  koumyss,  292,  293; 
kourayss  sanatoria,  294;  cod-liver  oil,  keffir,  etc.,  294;  arsenic,  295; 
creosote,  guaiacol  and  guaiacol  carbonate,  295,  296,  297;  the  last 
stage,  297;  modern  bacteriology  in  its  relation  to  the  ti-eatment  of 
tuberculosis,  297,  298. 


The  Climatic  Treat.mbn't  of  Chkoxic  Pulmon^ary  TtiBEBCULOsia, 
298-316. 

^feglect  of  the  subject,  293 ;  climate  in  relation  to  climatic  therapy, 
298,  299;  the  complexity  of  climatic  influences,  299;  Webber's  classi- 
fication of  climates,  299. 

The  Elements  of  Climate,  300-303.  —  The  temperature,  300;  sun- 
light, air,  etc.,  300-303. 

Former  climatic  treatment  of  tuberculosis,  303 ;  by  residence  in 
the  mountains,  303,  304;  the  supposed  curative  agencies  of  high 
altitudes,  304;  Brehmer  and  his  sanatorium  at  Gorbersdorf,  304,  305; 
his  theories  and  their  refutation;  his  success,  305,  306;  Davos  as 
compared  with  Gorbersdorf  and  other  sanatoria,  303,  307;  change  in 
the  climatic  treatment  of  tuberculosis,  307;  Russia  as  compared 
vrith  Western  Europe  as  a  resort  for  tuberculous  patients,  308,  309; 
climatic  treatment  at  home :  cases  illustrating  same,  309-315 ;  cases 
for  which  trips  are  indicated,  316. 

TwEXTY-SECOND  Case. — -Croupous  pneumonia,  317-324. 

Anamnesis  and  mode  of  living,  317 ;  Course  of  disease,  318,  323, 
324;  Diagnosis,  318;  differential,  319;  Objective  examination,  318; 
Prognosis,  319;  Treatment,  320,  323,  324. 

Treatment  of  high  temperature  in  pneumonia,  320,  321 ;  of  dysp- 
noea, pains  and  cough,  321,  322,  323. 

A  Few  Notes  on  Objective  Examination,  325-331. — The  importance 
of  morbid  symptoms  in  semiotics,  as  compared  to  those  necessary  for 
diagnosis,  325 ;  their  necessary  differentiation,  326 ;  the  nature  of  the 
vesicular  respiratory  murmur,  327 ;  of  the  bronchial  respiratory  mur- 
mur, 327;  the  indefinite  respiratory  murmur,  rough  breathing,  327, 
328;  varieties  of  rales,  328,  329;  the  percussion  sound,  329;  determi- 
nation of  dimensions  of  heart,  liver  and  spleen,  329,  330;  the  pulse, 
330,  331. 

ELEMENTS   OF   BALNEOTHERAPY. 

Balneotherapy  for  the  Practical  Physician,  332-355. 

Necessity  for  clinical  individualization  of  balneotherapy,  332, 
333 ;  the  differences  in  the  external  and  internal  employment  of  min- 
eral waters,  333;  the  effect  of  the  temperature  of  the  water,  335-338; 
effects  of  the  component  parts  of  the  waters:  sodium  chloride  and 
carbonate,  carbonic  acid,  sulphur,  organic  acids,  etc.,  338,  339;  the 
effect  of  mechanical  influences  during  the  external  employment  of 
mineral  waters,  339;  the  various  classes  of  waters:  1.  the  chemically 
indifferent,  their  effects  and  use  (Schlangenbad,  Ragatz,  Gasteiu,  etc.), 
340;  individualization  necessary  in  their  employment,  340;  mineral 
moor,  341,  342;  the  influence  of  climate  at  the  watering-ijlaces,  342; 
conditions  of  life  there,  343;  2.  salt  loaters,  their  use  and  effects, 
(Kreutznach,  Wiesbaden,  Soden,  Ischl,  Gmunden,  Reichenhall,  etc.), 
343,  344;  3.  carbonated  waters,  indications  for  employment,  345;  4. 
salt  waters  which  are  at  the  same  time  carbonated,  345  ;  5.  mineral  muds 
employed  in  the  form  of  mud-baths,  indication  for  use  in  diseases  of 
women,  :?45,  346;  mineral  muds  employed  directly  as  such,  346;  sea- 


bathing,  its  effective  agencies,  346,  347;  hot-air  baths,  fir-tree  baths, 
347;  hydrotherapy,  modes  and  effects  of  application,  347,  348;  half- 
baths,  rubbings,  etc.,  349;  possibility  of  balneotherapeutic  treatment 
at  home,  349;  the  Russian  bath,  349,  350;  seasons  of  the  year  for 
balneotherapeutic  treatment,  duration  of  course  of  same,  350;  out- 
line  of  the  diseases  in  which  balneotherapy  is  employed,  ;350-355. 


CHOLERA,    PARTICULARLY   ITS   TREATMENT. 

Pages  356-384. 
Introductory  notes,  356,  357;  the  nature  of  cholera,  358;  the  former  clas- 
sification of  infectious  diseases  and  its  unreliability  at  the  present 
time,  358,  359;  the  three  important  factors  in  the  development  of  a 
cholera  epidemic,  359;  Pettenkofer's  theories  concerning  the  influ- 
ence of  the  soil-water,  359;  Hueppe's  investigations  as  to  the  spread 
of  the  epidemic  in  Hamburg,  360;  Koch's  failure  to  recognize  the  im- 
portance of  the  surrounding  conditions  of  life,  361 ;  Huepi^e's  theories 
concerning  the  influence  of  the  intestinal  tract  on  the  growth  of  the 
bacteria,  361,362;  the  unreliability  of  experimentation,  362;  occur- 
rence of  cholera  among  washerwomen,  362;  the  basis  for  considering 
cholera  as  a  contagious  disease,  362,  363;  varieties  and  course  of  the 
disease:  choleraic  diarrhoea,  cholerine,  363,  364;  genuine  cholera, 
symptomatology,  364,  365;  causation  of  the  algid  stage,  365,  366,  1367; 
reaction  period  and  its  attendant  disturbances,  367,  368;  preventive 
measures:  quarantine  in  Europe  and  Asia,  368,  369;  over  the  Suez 
Canal,  369;  the  individual  quarantining  of  patients,  369,  370;  disin- 
fective  measures,  370;  supervision  over  arrivals,  370,  371;  the  results 
of  these  measures  in  various  parts  of  Russia  during  the  recent  cholera 
epidemic,  371;  the  individual  measures  of  precaution,  371,  372;  the 
treatment:  the  unreliability  of  statistics  as  regards  the  value  of  the 
various  methods  of  treatment,  372,  373;  absence  of  any  specific,  373, 
374;  the  necessity  for  distinguishing  the  symptomatic  from  the  rou- 
tine treatment,  374 ;  treatment  of  diarrhoea :  its  varieties,  375 ;  laxatives, 
376 ;  calomel  not  an  "  anti-choleraic  "  remedy,  376,  377 ;  opium  in  diar- 
rhoea and  the  reasons  for  its  employment,  377,  378;  bismuth,  clysters, 
etc.,  379,  380;  Cantani's  treatment  of  choleraic  diarrhoea,  380;  effect 
of  enteroclysmata.  380,  381 :  warm  baths,  etC/,  381 ;  treatment  of  chol- 
erine, 381,  382;  of  the  algid  stage  of  cholera  proper,  382,383;  of  the 
reaction  period,  383,  384;  nature  of  cholera  nostras,  384. 


SUPPLEMENTS. 


Ox  Bloodletting,  387-406. 

The  recent  history  of  bloodletting  and  its  present  condition,  387, 
388;  neglect  of  the  subject,  388,  389;  former  failures  in  its  employ- 
ment and  reasons  for  same,  389,  3^0;  opposition  to  it,  390;  depletive 
and  derivative  effects,  391;  depletive  bloodletting:  venesection  in  dis- 
turbances of  the  cerebral  circulation,  :391,  :392;  in  threatening  apo- 
plexy, 392 ;  in  diseases  of  the  heart,  392  ;  in  croupous  pneumonia,  393 ; 
local  bloodletting,  :593;  method  of  application,  394;  wet  cups,  394; 
their  effect,  394,  :395 ;  where  applied,  395;  care  in  applying  necessary, 


395;  local  depletive  blood-extraction,  396;  derivative  bloodletting: 
nature  of  liaemorrboids,  396;  an  angioneurosis.  397;  case  proving  this 
supposition,  397;  etiology  of  hsemorrlioids,  398;  how  derivative  blood- 
letting from  the  anus  originated,  398;  effects  of  this  bloodletting,  399; 
case  v^here  it  was  employed.  399,  400;  care  in  using  tamponade  of  na- 
sal cavity  for  nosebleed,  400;  indications  for  derivative  bloodletting: 
1.  in  the  region  of  the  head,  401,  402;  2.  in  the  region  of  the  spinal 
column,  402,  403;  3.  in  the  region  of  the  chest,  in  various  hsemopty- 
ses,  403,  404;  in  the  abdominal  region,  in  inflammation  of  large 
haemorrhoidal  nodes,  404;  the  method  of  employing  derivative  blood- 
letting, 404,  405;  the  time  of  the  day,  position  of  the  patient,  site  of 
operation,  number  of  leeches,  etc.,  405,  406;  repetition  of  derivative 
bloodletting,  406. 

2.  Calomel.  —  In  hypertrophic  cirrhosis  of  the  liver  and  in  general  thera- 

py, 407-435. 

History  of  calomel  therapy  in  England,  Germany  and  Eussia,  407, 
408;  author's  experience  with  calomel,  408;  physiological  action  of 
the  drug  according  to  Binz,  Shiffi,  Weiss  and  Sokoloff,  408,  409 ;  the 
English  practice  as  regards  calomel,  409,  410 ;  calomel  in  severe,  es- 
pecially febrile  cases  of  colic  from  biliary  calculi:  cases,  410,  411-415  ; 
Method  of  employing  the  drug,  415,  416,  417;  calomel  compared  with 
castor  oil,  417;  case  of  hypertrophic  cirrhosis  of  the  liver,  417-427 ; 
calomel  in  facial  erysipelas,  427 ;  in  typhoid  fever,  428  ;  in  croupous 
pneumonia,  428;  in  acute  nephritis,  429;  in  diseases  of  the  biliary 
passages,  430,  431;  diagnosis  of  biliary  calculi,  431,432;  calomel  in 
catarrhal  jaundice,  432-435. 

3.  Syphilis  of  the  Lungs,  436-445. 

Pulmonary  tuberculosis  in  syphilitic  patients,  437;  cases  of  syphi- 
litic pneumonia,  437;  diagnosis  of,  441;  syphilitic  pneumonia  com- 
Ijlicated  by  pulmonary  tuberculosis,  441-444;  treatment  of,  445;  case 
exemplifying  this  treatment,  445. 

4.  Syphilis  of  the  Heakt,  446-459. 

Lack  of  knowledge  on  the  clinical  aspect  of  cardiac  syphilis,  447; 
cases  of  syphilis  of  the  heart  (syphilitic  myocarditis,  syphilitic  affec- 
tion of  the  cardiac  muscle),  447,  448 ;  character  of  the  majority  of  cases 
of  cardiac  syphilis,  449;  case  presenting  a  type  of  syphilitic  car- 
diac affection  (contemporaneous  syphilitic  affection  of  the  cardiac 
muscle  and  nerves),  449-451 ;  its  treatment,  451 ;  failure  of  digitalis  in 
same,  452 ;  condition  of  the  nervous  system  of  the  patient,  452 ;  data 
for  diagnosis  of  cardiac  syphilis,  454;  its  treatment,  454,  455;  the 
milk  treatment  of  disease  of  the  heart,  455;  Spanish  flies  in  angina 
pectoris,  456 ;  case  of  aneurism  of  the  aorta  due  to  syphilitic  aortitis, 
457-459. 

5.  Treatment  of  Fevee,  460-463. 

Certain  symptoms,  among  them  fever,  as  protecting  agencies  to 
the  organism,  460 ;  treatment  of  fever  in  acute  infectious  diseases,  460, 
461 ;  use  of  cool  baths,  462 ;  cold  sheet,  462 ;  use  of  antipyrine,  anti- 
febrine  and  phenacetine,  462;  use  of  quinine,  463;  fever  in  pulmonary 
tuberculosis,  463 ;  in  septicasmia  and  pyaemia,  463. 


INTRODUCTION 


TO 


CLINICAL   EXERCISES. 


THREE  LECTURES. 


Gentlemen  :  — 

Before  we  begin  our  clinical  exercises,  it  is  necessary  that 
we  understand  the  nature  of  the  clinic  and  its  importance  in 
the  matter  of  medical  education  and  in  scientific  medicine. 
The  duty  of  explaining  this  importance  devolves  principally  on 
me,  as  the  teacher  at  the  Faculty  Therapeutical  Clinic,  this 
last  being,  as  we  shall  see  later,  the  first  general,  as  contrasted 
with  the  special,  clinic,  which  you  come  to  attend. 

The  Importance  of  the  Clinic  in  Medical  Education.  — 
You  desire  to  become  physicians,  that  is,  to  learn  the  art  of 
treating  and  preventing  diseases.  —  It  is  impossible  to  learn 
this  without  the  knowledge  of  disease  and  of  therapeutic  means. 
You  cannot  interpret  disease,  unless  you  know  what  constitutes 
the  normal  condition.  The  course  of  medical  studies  is  there- 
fore such  as  to  teach  you  first  what  constitutes  the  normal 
condition  (Anatomy  and  Physiology),  and  later  the  nature  of 
diseases,  their  treatment  and  the  nature  of  the  remedies  (gen- 
eral and  special  Pathology,  and  Therapeutics  with  Pharmacol- 
ogy). Until  the  present  you  have  occupied  yourselves  with 
the  above-mentioned  sciences ;  now,  in  due  order,  follows  your 
acquaintance  with  diseases  and  their  treatment  in  practice  : 
this  necessity  of  medical  education  is  fulfilled  by  the  clinic,  i.  e. 
by  clinical  instruction  and  clinical  exercises.*     What  is  the  in- 

*  "  Clinic  "  is  derived  from  the  Greek  kXlvtj,  a  bed,  a  couch,  on  which 
the  patient  reposes ;  as  used  in  these  lectures  it  refers  to  a  hospital  con- 
nected with  the  medical  school  for  purposes  of  practical  teaching. 


_  2  — 

fluence  of  clinical  exercises  or  generally  of  observation  and 
treatment  of  the  sick,  even  when  outside  of  the  clinic,  on  the 
course  of  medical  education? 

The  student,  on  his  coming  to  the  clinic,  is  well  informed, 
but  in  a  purely  abstract  manner,  of  all  the  possibilities  of  a 
pathological  process,  and  the  potentialities  of  therapeutic  ac- 
tion. All  this  information  is,  as  it  were,  evenly  distributed  in 
his  mind :  there  is  no  occasion  for  one  certain  part  of  it  to  be- 
come more  prominent  than  another. 

In  the  clinic,  as  generally  in  practice,  the  phenomena  of  the 
pathological  processes,  and  the  reasons  for  therapeutic  action, 
as  well  as  the  action  itself,  present  themselves  not  in  an  ab- 
stract form,  but  under  all  the  conditions  of  a  given  case ;  the}^ 
may  appear  to  one  physician  in  a  greater  number  than  they  do 
to  another,  but  they  never  will  appear  to  one  m  such  numbers 
and  varieties  as  to  exhaust  all  the  possibilities  indicated  by 
pathology  and  therapeutics.  Under  such  an  influence  of  the 
clinic  or  of  practical  activity  m  general,  certain  medical  infor- 
mation will  take  precedence  over  others  in  the  mind,  and  will 
thus  come  forward,  at  the  same  time  grouping  itself  otherwise 
than  in  the  systematic  studj^  of  pathology  and  therapeutics  : 
for,  whereas  in  this  last  the  etiological  and  anatomo-pathologi- 
cal  points  of  view  are  chiefly  predominant,  in  clinical  and  in 
practical  work  in  general  the  diagnostic  and  therapeutic  con- 
siderations al'e  chiefly  taken  into  account.  Systematic  exposi- 
tion starts  with  the  definition  of  the  disease  in  the  direction  of 
its  picture ;  ^vhereas  in  the  clinic  we  begin  with  the  picture  of 
the  disease  and  deduct  its  definition  therefrom.  This  difference 
creates  the  practical  physician,  who.  knowing  the  real  nature  of 
the  disease  and  the  influence  of  medical  means  thereon,  appre- 
ciates correctl}'  the  extent  of  the  pathological  process  and  the 
degree  of  effectiveness  of  the  remedial  agencies  :  he  is  thus 
enabled  to  quickly  concentrate  his  mind  on  the  two  most 
important  aims  of  practical  medicine,  namely,  the  recognition 
of  the  disease  and  its  treatment.  (3n  the  other  hand,  this  same 
difi^erence  may  naturally  become  the  foundation  of  a  future 
routine  tendency  in  medical  practice.  —  Comprehending  then 
the  influence  of  clinical  and  of  practical  activity  in  general,  and 


the  possibility  of  the  two  above-named  results  therefrom  —  a 
desirable  and  an  undesirable  one  —  what  must  be  the  aims  of 
clinical  teaching  ?  To  educate  the  students  into  practical  and 
as  perfect  physicians  as  possible,  the  teacher  must  see  to  it  that 
they  acquire  a  regular  method^  following  a  laid-out  plan,  accord- 
ing to  which  the  clinical  exercises,  that  is,  practical  medical  ac- 
tivity, are  to  be  conducted,  thus  avoiding  irregular  clinical 
teaching.  To  prevent  the  development  of  a  routine  habit,  he 
must  individualize  his  cases,  that  is,  point  out  their  special  char- 
acteristics. Of  course,  the  mastering  by  the  future  physician 
of  a  method  and  the  acquisition  of  the  skill  in  individualizing 
is  a  rather  slow  process  at  the  beginning ;  but  once  acquired, 
their  possessor  finds  them  at  his  command  sooner  and  to  greater 
advantage,  than  the  man  who  is  not  habituated  to  them.  The 
acquisition  by  the  students  of  a  method  and  of  skill  m  individu- 
alizing must  be  the  chief  aim  of  the  teacher,  as  contrasted  with 
the  tendency  to  convert  the  clinic  into  a  kaleidoscope,  and  to 
show  in  a  short  space  of  time  —  always  limited  —  all  the  diseases 
o'f  the  special  branch  of  pathology  in  all  their  varieties,  combina- 
tions, and  under  all  conditions.  It  is  impossible  to  show  all  in 
one  year,  —  not  even  in  ten  ;  and  to  insist  upon  an  impossibility 
is  unreasonable.  —  Whoever  has  acquired  a  method  and  the 
habit  of  individualizing,  will  quickly  familiarize  himself  with  any 
new  case  which  may  present  peculiarities  unknown  to  him  be- 
fore ;  and  such  new  cases  are  met  with  quite  frequently  even 
by  the  very  experienced  physician,  the  more  so  by  the  beginner : 
for  such  is  the  peculiarity  of  the  medical,  as  of  every  other  prac- 
tice, that  is,  of  an  activity  amidst  conditions  of  real  life.  The 
teacher  should,  surely  enough,  introduce  to  his  students  the 
principal  morbid  varieties  and  typical  cases  of  that  particular 
branch  of  pathology,  to  which  his  clinic  is  especially  devoted. 

In  accordance  with  their  aims  the  clinics  are  divided  into 
different  varieties:  — 

A.  Those  conforming  to  the  grades  of  medical  studies.  — 
1,  The  Propcedeutic  Clinic  (introductory,  from  Greek  TrpoTraiSeu'etv, 
teach  beforehand),  which  is,  properly  speaking,  practical  semi- 
otics, i.  e.  it  familiarizes  the  students  with  the  signs  of  diseases 
and  with  the  groups  of  signs  in  real  life.      In  such  a  clinic  the 


—  4  — 

teacher  cannot,  while  devoting  his  time  to  this  subject,  conduct 
any  thorough  clinical  investigation  concerning  the  diagnosis, 
prognosis,  and  treatment  of  a  case ;  besides,  the  students  are 
not  sufficiently  prepared  to  profit  by  it. 

2.  The  Faculty  Clinic  is  the  first  complete  clinic,  in  which 
the  teacher  conducts  before  his  hearers  the  above-mentioned 
medical  acts,  methodically  and  individualizing  each  case,  and 
presents,  therefore,  a  smaller  number  of  patients. 

3.  The  Hospital  Clinic.  —  In  this  the  teacher  can  do  his  work 
more  rapidly,  and  goes  over  a  greater  number  of  cases,  thus  in- 
creasing the  experience  of  the  students,  who  had  been  prepared 
for  this  by  the  preceding  clinic. 

4.  Clinic  for  the  out-patients  (ambulator3^)  —  While  the  more 
serious  affections  are  usually  to  be  seen  in  the  hospitals,  in  the 
out-patient  department  we  see  a  great  many  others ;  namely, 
the  less  serious  ones,  that  do  not  go  to  the  hospital,  and  the 
serious  forms  at  their  beginning.  The  out-patient  department 
affords  also  opportunities  for  observing  the  course  and  treat- 
ment of  diseases  not  under  hospital  conditions,  but  under  the 
variable  surroundings  of  every-day  life ;  as  their  attendance 
requires  a  certain  degree  of  practical  maturity,  they  should  be 
in  charge  of  those  students  who  have  gone  through  the  station- 
ary clinics  (the  preceding  ones)  ;  but  this  is  not  always  adhered 
to,  nor  is  it  always  possible  to  do  so. 

B.  As  to  their  contents,  clmics  are  divided  mto  general  and 
special.  The  reason  for  the  existence  of  the  special  clinic 
lies  in  the  great  general  law  of  progress  :  the  subdivision  of 
labor.  As  a  result  of  the  clinician's  ability  to  confine  his  work 
to  one  special  branch  of  pathology,  he  perfects  himself  in  it, 
becomes  better  able  to  teach  it,  and  assists  in  advancing  it 
more  rapidly  as  a  science.  The  number  of  special  clinics  is 
therefore  continually  on  the  increase  :  thus  in  the  last  few  de- 
cades the  former  special  clinics  in  surgery,  obstetrics  and  oph- 
thalmology, were  increased  by  the  addition  of  those  in  gynae- 
cology, nervous  diseases,  insanity,  skin  diseases,  venereal  and 
diseases  of  the  genito-urinary  tract. 

It  is  rather  more  difficult  to  define  the  character  of  the  gen- 
eral  clinic.     What   is   it.  and  what  are  its  aims  ?     The  name 


—  5  — 

general  clinic  can  only  be  applied  to  the  clinic  of  internal 
diseases.  The  ailments  usually  treated  in  such  a  clinic  refer 
to  organs  whose  functional  activity  forms  the  basis  of  animal 
metabolism,  namely,  the  organs  of  nutrition,  respiration,  circula- 
tion and  of  the  secretions,  —  then  disturbances  of  the  processes 
of  the  animal  metabolism  itself,  acute  and  chronic  contagious 
diseases,  functional  disturbances  of  the  nervous  system  which 
are  inevitably  met  with  in  all  these  disorders  (we  can  leave  aside 
the  organic  diseases  of  the  nervous  system  that  belong  properly 
to  the  clinic  of  nervous  diseases),  and  at  times  diseases  belong- 
ing to  the  special  clinics,  particularly  affections  of  the  female 
genital  organs. 

What  conditions  have  secured  for  the  clinic  of  internal 
diseases  its  significance  and  its  contents  ?  The  question  natu- 
rally arises,  whether  it  were  not  possible  and  more  advantageous 
to  distribute  all  that  the  clinic  of  internal  medicine  claims,  over 
special  clinics  for  diseases  of  the  chest,  abdomen,  etc.  ?  There 
is  not  the  slightest  doubt  but  that  clinics  of  such  a  nature 
would  be  just  as  useful  as  any  other  special  clinics ;  but  they 
could  not  possibly  replace  the  clinic  of  internal  diseases  in  its 
present  form.  The  fact  is,  that  the  special  clinic  suffers  from 
one  radical  defect :  the  difficulty  that  the  specialist  clinician 
experiences  even  in  satisfactorily  determining,  in  the  given 
case,  the  general  condition,  the  condition  of  other  parts  of  the 
organism,  after  he  had  recognized  in  the  most  thorough  manner 
the  defect  of  the  organ  of  his  specialty ;  and  the  more  perfect 
the  specialist,  the  greater  this  difficulty,  as  devotion  to  his 
specialty  must  needs  have  alienated  him  from  the  others.  The 
specialists  are  well  aware  of  this  defect,  point  at  and  struggle 
against  it,  but,  as  every-day  experience  proves,  cannot  remove 
it,  because  it  is  organically  connected  with  the  very  nature  of 
specialization. 

What  would  become  of  medical  teaching  and  of  medical  sci- 
ence, if,  possessing  only  special  clinics,  we  were  deprived  of  one, 
that  would  have  as  its  principal  aim  the  teaching  of  the  import- 
ance of  connecting  all  the  phenomena  of  a  given  case,  so  that 
a  general  conclusion  about  it  may  be  arrived  at,  and  thus  lead 
us  to  the  physician's  chief  duty  —  application  of  remedial  agents? 


—  6  — 

Without  such  a  clinic  the  education  of  a  phj'sician  is  not  to  be 
thought  of.  And  such  a  clinic  is  the  one  of  internal  diseases 
with  the  above-mentioned  contents ;  occupying  itself  with  the 
simultaneous  ohservation  of  disorders  of  those  portions  of  the 
organism  that  are  chiefly  concerned  in  connecting  all  its  parts 
in  common  ;  that  is,  the  simultaneous  observation  of  disturbances 
of  functions  that  form  the  basis  of  animal  metabolism,  of  the 
metabolism  itself  and  of  the  functions  of  the  nervous  sj^stem. 
This  it  is  that  characterizes  the  pieculiarity  of  the  clinic  of  inter- 
nal diseases  and  entitles  it  to  the  name  of  a  general  clinic.  Not- 
withstanding the  importance  of  the  surgical  clinic,  it  does  not 
have  the  character  of  a  general  one,  as  the  subjects  of  its  treat- 
ment do  not  possess  the  same  importance  in  the  comprehension 
of  the  common  connection  of  pathological  phenomena,  as  do  the 
subjects  treated  of  in  a  clinic  of  internal  diseases.  You  will  see 
from  the  above,  that  the  pediatric  clinic  has  the  character  of  a 
general  one.  Our  university,  as  also  the  majority  of  universities, 
has  two  clinics  of  internal  diseases  —  the  faculty  clmic  and  the 
hospital  clinic.  As  you  attend  the  faculty  clinic  first,  it  —  the 
faculty  clinic  of  internal  diseases  —  consequently  is  the  first 
complete  and  at  the  same  time  general  clinic  which  the  student 
sees :  it  is  the  true  clinical  school  of  the  medical  department. 
From  this  fact  it  derives  its  importance  and  in  it  is  laid  the 
basis  of  your  future  medical  activity. 

While  discussing  the  importance  of  the  clinic  and  of  clinical 
exercises  in  the  course  of  medical  education,  we  must  make  some 
necessary  remarks  of  a  general  nature  on  the  method  of  con- 
ducting these  exercises. 

What  is  principally  embraced  by  clinical  exercises  ?  We  usu- 
all}^  have  to  define  the  nature  of  the  disease  (^examination  and 
diagnosis^,  its  future  course  and  its  termination  (prognosis'),  and 
to  order  a  plan  of  treatment  and  execute  it,  being  guided  by  the 
course  of  the  disease  (ohservation).  The  clinical  exercises,  as 
we  explained  above,  must  be  conducted  according  to  a  method 
and  to  a  process  of  individualization.  As  regards  a  method,  I 
have,  after  several  attempts  in  the  beginning  of  my  clinical 
and  practical  activity,  adopted  the  following  one  as  the 
best :  — 


—  7  — 

1.  Examination.  — I  begin  my  inquiry  with:  What  ails  the 
patient^  and  for  hoiv  long  a  time  /  The  patient,  in  the  majority 
of  cases,  does  not  distinguish  in  his  history  the  present  from 
the  past,  confounds  the  symptoms  referable  to  diseases  of  one 
portion  of  the  body  with  those  of  another,  the  course  of  the 
disease  with  the  results  of  the  applied  treatment,  supplies  you 
with  unnecessary  information,  and  is  generally  incoherent. 

In  the  beginning  of  my  practice  I  used  to  listen  to  these  tales, 
and  have  concluded  that  they  are  of  no  value  and  only  tend  to 
fatigue  both  the  ph3"sician  and  the  patient.  On  those  rare  occa- 
sions when  your  patient  is  either  an  intelligent  layman  or  a  physi- 
cian, stating  his  case  in  a  connected,  sensible  manner,  there  is  the 
danger  that  the  examiner  may  accept,  alongside  with  the  history 
of  the  case,  also  a  conclusion  about  the  disease  and  its  treatment, 

—  a  conclusion  which  had  been  formulated  either  by  the  patient 
himself  or  by  his  physicians,  as  even  the  manner  of  relating  the 
history  of  the  case  reflects  this  preconceived  opinion.  Such  a 
preconceived  conclusion  will  interfere  with  your  further  investi- 
gation and  may  prevent  you  from  arriving  at  a  correct  and  proper 
idea  about  the  disease  and  its  treatment. 

With  this  in  view,  I  usually  interrupt  the  patient's  narrative, 
explaining  to  him  that  I  desire  to  be  informed  in  a  concise 
manner  of  the  most  prominent  symptoms  he  suffers  from  (as 
dyspnoea,  pains,  weakness,  etc.),  and  of  their  duration  (in 
weeks,  months,  etc.),  that  I  will  later  conduct  the  inquiry  in 
due  order,  after  which  I  shall  be  ready  to  listen  to  his  story. 
With  this  I  beg  the  patient  to  answer  as  explicitly  as  possible, 
thus :  first,  to  affirm  or  deny  only  what  he  is  certain  of,  what  he 
remembers  well,  otherwise  to  say  :  "  I  do  not  know,  I  do  not 
remember ;  "  and  second,  to  answer  the  question^  and  that  only^ 
without  mixing  in  foreign  matter  not  related  to  it,  and  not  to 
be  carried  away  by  his  own  tale,  thus  distracting  the  physician's 
attention  from  the  principal  subject.  From  among  the  in- 
numerable multitude  of  inaccurate  answers  let  me  instance  for 
clearness'  sake  such  a  one :  "  Do  you  drink  any  tea,  and  if  yes, 
how  much?"     Answer:  "  I  am  not  a  particular  lover  of  tea  "  ; 

—  and  only  after  two,  three  or  more  questions  the  physician  finds 
that,  although  not  a  "  lover  of  tea,"  the  patient  imbibes  so  many 


glasses  or  cups  per  day.  More  time  still  is  wasted  uselessly  in 
listening  to  answers  which  become  tales  of  subjects  unconnected 
with  the  case.  I  advise  the  beginner  not  to  permit  any  such 
distractions.  As  a  circumstantial  examination  requires  time 
and  energy,  the  above-named  deviations  will  bring  it  about  that 
at  the  end,  when  the  important  point  will  have  been  reached  as 
to  what  treatment  is  to  be  applied  by  the  physician,  the  latter 
will  have  become  mentally  fatigued  just  at  the  moment  when 
his  whole  energy,  judiciousness  and  mental  clearness  are  to  be 
put  to  test.  However,  in  the  majority  of  cases  it  is  only  neces- 
sary at  the  beginning  to  correct  the  patient's  answers,  to  state 
explicitly  what  is  wanted  of  him,  namely,  as  concise  and  direct 
answers  as  possible,  and  the  further  interrogation  will  proceed 
smoothly.  It  is  self-evident,  that  to  receive  such  answers  the 
physician  in  his  turn  must  put  direct,  concise  and  simple  ques- 
tions. 

The  examination  of  the  patient  consists  of  inquiries  as  to  his 
present  condition  (^status  prcesens)  and  inquiries  relating  to  his 
past  (anamnesis).  When  examining  a  chronic  case,  I  usually 
begin  with  the  status  prcesens.,  as  the  information  obtained  facili- 
tates the  inquiries  about  the  past,  and  makes  the  data  concern- 
ing anamnesis  itself  more  intelligible.  In  recent  cases,  where, 
for  instance,  the  patient  has  been  ill  only  for  a  few  days,  and 
where  the  anamnesis  is  on  this  account  short,  it  is  much  more 
convenient  to  begin  with  the  latter.  It  would,  however,  be 
mere  pedantry  to  strictly  circumscribe  each  method  of  examina- 
tion :  particularly  so,  when  in  examining  the  present  state  we 
are  sometimes  compelled  to  make  special  inquiries  concerning 
the  past  without  going  into  a  full  examination  of  the  latter. 

The  examination  of  the  present  condition  (status  prwsens^ 
consists  of  interrogation  and  the  so-called  objective  examination, 
or  examination  through  the  sense-organs.  At  the  beginning 
both  interrogation  and  to  some  extent  objective  examination 
are  resorted  to  simultaneously,  the  latter  by  easily  accessible 
means,  as,  for  instance,  in  inspecting  the  tongue,  feeling  of  the 
pulse,  or  while  talking  to  the  patient,  the  physician  cannot 
help  noticing  the  latter's  condition,  the  state  of  nutrition 
(whether  fat  or  thin),  the  appearance  of  the  superficial  tissue 


_   9  — 

(whether  plethoric  or  anaemic,  cyanotic,  icteric,  cachectic,  etc.), 
his  physical  and  mental  condition  (movements  of  the  body, 
facial  expression,  mode  of  speaking,  etc.).  But  a  complete 
objective  examination,  when  it  becomes  necessary  to  undress 
the  patient  or  to  resort  to  such  means  as  the  examination  of 
the  urine,  sputum,  etc.,  is  much  more  convenient  to  make  after 
you  will  have  finished  your  inquiries  about  his  present  and 
past  condition. 

In  interrogating  about  the  status  prcesens  I  first  of  all  seek  for 
information  about  the  most  important  conditions  surrounding  the 
patient's  life,  and  about  his  mode  of  living. 

1.  The  locality.  —  Whether  damp,  malarial,  or  dry,  dusty  : 
whether  open  to  winds  or  not,  and  so  on. 

2.  The  dwelling-place.  —  Dimensions,  flooring,  position  of  bed- 
room, temperature  and  ventilation,  condition  of  water-closet, 
and  so  on.     Where  is  the  work  of  the  day  performed  ? 

3.  How  does  the  patient  wash  himself?  Outdoor  bathing, 
public  hot  baths,  simple  house-bathing,  sponging? 

4.  Clothing  in  general  and  particularly  the  protection  of  the 
abdomen  (sashes  and  corsets)  and  feet  (covering  —  warm  or 
cold,  roomy  or  tight). 

5.  What  nervines  is  the  patient  addicted  to :  tobacco,  tea, 
coffee,  wine,  whiskey,  beer  ? 

6.  What  drinks:  ordinary  water,  or  alkaline  (soda,  seltzer), 
kvass,*  milk? 

7.  Food  —  meat  or  otherwise  ;  light  or  heavy,  frequency  of 
meals  ? 

8.  Family  life,  single,  retired. 

9.  Children,  abortions. 

1(X  Does  the  patient  get  sufficient  aleep  or  not?  Duration 
of  the  sleeping  hours.     How  often  is  he  sleepy  ? 

11.  Mental  and  physical  activity  f     Rest? 

12.  How  much  of  the  day  is  spent  out  of  doors  and  how  much  in 
confined  rooms  ? 

*  A  fermented  drink  in  general  use  in  Russia,  taking  the  place  of  beer 
of  other  countries.  Common  kvasa  is  made  from  an  infusion  of  raised 
rye-flour  or  dough,  or  of  other  flour  or  baked  bread,  with  malt.  Finer 
kinds  are  made  from  apples,  raspberries,  or  other  fruit,  without  malt.  — 
Century  Die. 


—  10  — 

We  next  inform  ourselves  of  the  patient's  condition  by  carry- 
ing our  inquiries  along  an  ad  opted  plan,  which  is,  of  course,  the 
essence  of  systematic  examination.  The  beginner,  without 
having  acquired  this  method,  and  not  appreciating  the  necessity 
of  it,  conducts  his  inquiries  without  order,  and  is  therefore 
liable  to  be  influenced  in  arrivmg  at  the  diagnosis  by  the  first 
impression  produced  on  him  by  the  patient's  complaints  (as,  for 
instance,  difficulty  in  breathing,  pain  in  the  side,  cough),  on  the 
strength  of  which  he  is  led  to  think  of  a  certain  disease  ;  and 
without  going  into  details  about  the  condition  of  the  whole  or- 
ganism, he  hopes  to  quickly  diagnosticate  the  case  with  the 
aid  of  a  few  questions  relating  to  his  assumed  ailment.  But 
bitter  experience  will  teach  him  —  if  he  only  be  capable  of  self- 
improvement —  that  such  reasoning  is  deceptive  and  is  justly 
condemned  by  experience,  and  that  the  only  reliable — although 
somewhat  slower  and  more  laborious  —  method  of  examination, 
is  the  complete  one,  conducted  in  accord  with  a  certain,  once 
established  order.  In  the  basis  of  my  system  of  examination, 
which  experience  has  taught  me  to  consider  the  best,  I  put  the 
union  of  two  prmciples  :  the  physiological  one  (systems  and  or- 
gans), and  the  topographical  one  (neighboring  parts).  There 
may  be  others,  but  the  first  condition  of  ever}'  method  requires 
that  the  questions  include  all  that  is  most  important. 

1.  Appetite  and  thirst. 

2.  The  tongue,  teeth,  mouth  and  throat. 

3.  The  stomach.  Is  the  introduction  of  food  followed  by 
belching,  burning,  heaviness,  paui,  nausea,  vomiting ;  any  pains 
when  the  stomach  is  empty  ? 

4.  Intestines.  Character  of  stool,  regular  (i.  e,  daily),  of 
sufficient  quantity,  evacuation  of  normal  consistency  and  form, 
—  or  irregular  ?  If  the  latter,  do  not  content  yourself  with  the 
general  statement  of  an  existing  constipation  or  diarrhoea,  but 
inquii"e  fully  as  to  just  what  irregularity  there  is.  With  this 
m  view,  take  a  certain  period  of  time  previous  to  the  examina- 
tion, saj^  a  week  or  more,  if  the  patient  can  call  it  to  his 
memory,  and  inquire  about  the  condition  of  the  stool  on  each 
day  of  this  period :  whether  a  constant  diarrhoea,  or  a  constant 
constipation,  that  yielded  only  to  injections  and  laxatives,  or. 


—  11  — 

what  is  most  frequent,  both  coustipatioii  and  diarihfjea  alternat- 
ing with  each  other.  If  the  movements  of  the  bowels  were  of 
late  exceptionally  regular,  or  constipated,  or  loose,  inform  your- 
self of  their  usual  condition.  If  the  patient  resorts  to  laxatives, 
find  what  they  are  and  in  what  doses.  If  he  uses  enemata,  — 
of  what  and  at  what  time:  at  bed-time,  when  the  system  is 
fatigued,  and  the  nervo-muscular  apparatus  in  general,  as  well 
as  that  of  the  intestinal  tract,  reacts  less  readily,  —  or  in  the 
morning,  after  a  night's  rest  and  the  morning  tea  or  coffee, 
when  the  patient  feels  an  inclination  to  stool  not  of  itself  suffi- 
cient to  clear  the  bowels,  but  strong  enough  to  do  so  effectually 
with  the  aid  of  an  mjection.  Does  not  the  patient,  as  a  general 
thing,  resist  the  tirst  inclination  to  stool,  thus  preventing  the 
emptying  of  the  bowels  (the  most  important  and  frequent 
cause  of  constipation^ '!  Does  he  empty  at  stated  times  the 
bowels,  when  constipated,  so  as  to  avoid  overloadhig  of  the 
same  and  the  possibility  of  a  consequent  diarrhoea?  What 
kind  of  food  or  drmk,  or  what  conditions  in  general  produce 
constipation  or  diarrhoea?  Such  a  circumstantial  inquiry  will 
at  once  lead  to  a  full  recognition  of  the  irregularities  in  the 
case,  —  irregularities,  that  are  so  important  by  their  frequency 
and  influence  on  the  rest  of  the  organism :  you  will  seldom  in- 
deed find  a  patient,  whatever  the  disease  he  may  be  suffering 
from,  who  has  perfectly  regular  stools.  The  same  mquiry  will 
also  furnish  you  with  verj"  valuable  information  regarding  the 
therapy  and,  even  more  important,  in  respect  to  the  hygiene  of 
the  given  part  of  the  organism.  How  many  times,  for  instance, 
have  I  succeeded  in  effecting  a  cure  of  a  rebellious  constipation, 
by  simply  enjoining  upon  the  patient  not  to  resist  the  first  in- 
clination to  stool ;  or  in  persons  habituated  to  no  other  drinks 
but  warm  tea,  by  advising  to  diminish  the  quantity  of  the  latter 
and  to  take  half  a  glassful  of  water  of  ordinary  temperature, 
from  one  to  three  times  a  day,  each  time  one  and  one-half  oi 
two  hours  before  a  meal.  The  reason  for  mv  dilating'  on  the 
subject  of  irregular  rectual  evacuations  lies  in  the  fact  that  we 
are  often  liable  to  pass  over  this  subject  and  its  treatment  in  a 
rather  hasty  and  superficial  mamier. 

5.    The  anus.     Any  lumps?    Do  any  haemorrhages  take  place 


—  12  — 

from  the  anus,  and  by  what  phenomena  in  the  rest  of  the  or- 
ganism are  they  accompanied? 

6.  How  does  the  urinary  bladder  empty  itself?  Is  the  urine 
ever  red  and  turbid?  It  is  here  that  I  inquire  about  swelling 
of  the  lower  extremities  (the  parts  of  the  body  in  which  the 
phenomena  of  dropsy  make  their  first  appearance). 

7.  The  male  genital  organs :  the  condition  of  jyoientia  virilis. 
How  frequent  are  the  connections  ?  Does  the  patient  feel 
weak  after  them  (this  is  very  important  in  neurasthenia)  ? 
Masturbation,  past  or  present ;  pollutions.  Also  inquire  about 
diseases  (past  or  present)  that  originate  most  frequently  through 
sexual  contact,  as  gonorrhoea,  chancre,  syphilis,  iis  regards 
this  last,  I  consider  it  of  paramount  importance  to  be  convinced 
as  to  whether  the  patient  is  syphilitic  or  not;  and  it  is  quite 
superfluous,  I  think,  to  dispute  the  necessity  for  this.  If  con- 
venient, I  inquire  of  the  patient  whether  or  not  he  had  syphilis, 
but  do  not  rely  entirely  upon  either  the  positive  or  the  nega- 
tive reply,  but  verify  it  by  inquiring  as  to  whether  the  patient 
(if  a  woman)  has  had  any  children,  or  abortions  and  miscar- 
riages; whether  he  had  any  falling  of  the  hair  (particularly 
from  the  eye-brows  and  beard),  not  ascribable  to  any  cause ;  any 
eruptions,  and  of  what  nature;  are  there  any  scars  left? 
Were  there  before  or  are  there  now  any  nocturnal  pains  in  the 
bones  and  articulations  ;  any  chronic  catarrh,  etc.  ?  If,  on  the 
other  hand,  it  is  either  inconvenient  or  useless  to  put  the  ques- 
tion directly,  as,  for  instance,  to  a  woman,  m  whom  the  infec- 
tion might  have  passed  unobserved,  then  I  at  once  resort  to  the 
above  verifying  questioning.  If  such  inquiry  furnishes  me 
with  accurate  information,  I  continue  it  to  the  end.  But 
if  it  leads  me  back  into  the  anamnesis,  —  if  the  history  of 
the  apparent  or  doubtful  syphilis  has  been  intimately  connected 
for  a  long  time  with  the  history  of  other  morbid  processes 
in  the  given  case,  I  then  postpone  the  inquiry  until  I  have 
collected  complete  information  covering  the  past,  until  the  in- 
vestigation of  the  anamnesis.  This  observation,  as  to  how  far 
into  the  anamnesis  we  may  go  while  investigating  the  present 
condition,  not  only  refers  to  the  inquiry  about  syphilis,  but 
to  that  about  any  other  disease  of  the  organism. 


—  13  — 

8.  Female  genital  organs.  Former  deliveries  or  abortions. 
Condition  of  menstruation  before  and  now.      Leucorrhcea. 

9.  The  abdomen  in  general.  Well-marked  changes  in  the  size 
of  the  abdomen,  observed  even  when  the  patient  is  dressed, 
impress  themselves  on  one's  memory.  But  the  most  important 
inquiry,  regarding  the  abdomen  in  general,  consists  in  in- 
forming oneself  as  to  the  presence  or  absence  of  pains  in  that 
region ;  if  present,  whether  constant  or  paroxysmal,  and 
chiefly,  where  localized ;  this  last  gives  us  important  informa- 
tion as  to  the  source  of  the  pams.  In  case  the  patient  finds  it 
difficult  to  define  the  seat  of  the  pain,  we  assist  him  in  finding 
an  answer  by  asking  him  whether  the  pains  are  felt  all  over 
the  abdomen  or  more  to  the  middle  part  of  it;  whether  they  are 
accompanied  by  rumbling,  and  whether  they  are  relieved  by 
the  escape  of  gases  per  os  or  per  anu7n,  by  vomiting  or  by  a 
loose  stool  (gastric  and  intestinal  pains).  Is  there  more  pain 
in  the  upper  as  compared  with  the  lower  part  of  the  abdomen, 
—  more  on  its  right  than  on  its  left  side?  With  what  func- 
tional activities  do  they  coincide  (from  this  we  infer  as  to  their 
connection  with  the  liver,  kidneys,  ovaries,  uterus  and  urinary 
bladder)?  Are  there  any  pains  in  the  posterior  wall  of  the 
abdomen,  in  the  loins,  and  with  what  do  they  coincide :  with 
constipation,  with  pains  along  the  tract  of  the  ureters  or  with 
movements  of  the  back,  as  in  lumbago  m  general  (i.  e.  in  va- 
rious myopathies,  neuropathies  and  affections  of  the  vertebrae 
and  their  articulations  in  the  lumbar  region)  ? 

10.  The  chest  in  general,  and  also  the  organs  of  respiration  and 
circulatio7i.  If  there  are  pains  in  the  chest,  find  their  localiza- 
tion and  with  what  they  coincide :  as,  for  instance,  pain  in  the 
region  of  the  heart,  of  paroxysmal  nature,  transmitted  to  the 
left  arm  or  to  both  arms,  accompanied  by  a  sensation  of 
fright  and  anguish  (as  in  angina  pectoris) ;  pains  in  the  sides, 
aggravated  by  coughing,  as  in  pleuritis  of  tuberculous  and 
other  nature ;  pains  along  the  tract  of  the  intercostal  nerves 
(as  in  affections  of  the  same,  and  in  liver  and  kidney  colics)  : 
pains  in  one  half  of  the  chest  and  simultaneously  in  the  cor- 
responding arm,  with  this  also  tenderness  on  pressure  in  the 
supraclavicular  cavity  of  the  same  side  (neuritis  of    the   bra- 


—  14  — 

chial  plexus)  ;  pains  all  over  the  chest,  aggravated  by  pressure 
on  the  sternum  and  ribs  (as,  for  instance,  when  lying  on  the 
side),  coincidently  occurring  with  rheumatic  pains  in  the  ex- 
tremities and  agg-ravated  at  the  same  time  as  these  last  on  catch- 
mg  cold  (usually  gout  or  syphilis,  which  are  easily  differentiate 
ed ;  or  gout  and  syphilis  of  the  ribs  and  sternum,  at  times  with 
a  neuritis  of  a  similar  origin)  and  so  on.  —  Then  inquire  about 
difficulty  in  breathing  (dj'spnoea),  joaroa^^sws  of  clioking  (asthma), 
paljntation  of  the  heart,  coughing,  expeetoration,  spitting  of  bloody 
the  condition  of  the  nose  and  larynx  (alterations  in  the  voice). 
Examine,  the  pulse  and  inquire  about  the  conditifyn  of  the  circu- 
lation :  is  the  patient  subject  to  chilliness  in  general  or  in  par- 
ticular parts  of  the  body  (the  extremities,  feet,  and  particularly 
the  soles  of  the  feet)  ?  Is  he  subject  to  flashes  of  heat  in  gen- 
eral or  in  some  certain  part  (particularly  the  head)  ? 

11.  Is  there  any  febrile  condition  (chill,  heat,  or  only  weak- 
ness, loss  of  apj)etite,  and  thirst)  ?  If  not,  mquire  if  patient  is 
subject  to  any  habitual  feverish  condition,  and  what  does  it 
accompany :  for  instance,  catarrhal  conditions,  most  frequently 
of  the  respiratory  tract,  less  so  of  the  intestmes  and  urinary 
tract  (febris  cartarrhalis)  ;  or  it  may  accompany  rheumatic  pams 
in  the  extremities,  in  the  back,  chest  and  head  (febris  rheuma- 
tica)  ;  i.  e.  most  frequently  it  is  a  febrile  condition  accompanying 
an  exacerbation  of  gouty  or  syphilitic  pains,  or  both  of  these  to- 
gether, on  account  of  a  cold  or  for  some  other  reason.  Is  he  not 
subject  to  febrile  states  without  catarrh  and  '^  rheumatics,"  of  a 
more  or  less  clearly  defined  intermittent  nature,  coincident  with 
a  residence  in  a  malarial  region,  especially  during  autumn  and 
spring  ?  Is  there  a  fever  of  an  exhaustive  character,  accompan}"- 
ing  serious  diseases  of  important  organs,  most  frequently  tuber- 
culosis, cancer  or  syphilis  (particularly  frequent  with  syphilitic 
liver),  etc.  ? 

12.  Condition  of  nutrition  and  of  the  hcematopjoietic  system. 
Does  the  patient  tend  to  grow  full  and  fat.  or  thin  and  pale  ? 
Does  he  look  cachectic,  etc.  ? 

13.  Sleep,  whether  quiet  or  not ;  if  disturbed,  why  so  :  is  there 
cerebral  hypertelnia,  neurasthenia,  pains,  cough,  dyspnoea,  consti- 
pation and  an  overloaded  stomach  and  intestmes.  febrile  condi- 
tion, etc.  ? 


—  15  — 

14.  Mental  condition:  memory  and  the  faculty  of  reflection; 
state  of  mind,  —  hopeful,  pleasant  or  oppressed,  sad,  etc. 

15.  Headache.  Important  questions  to  ask :  does  your  head 
ache  or  not?  If  it  does  ache,  then,  the  whole  or  only  part  of  it, 
whether  the  temples,  the  back,  the  front,  the  top ;  and  what  is 
the  character  of  the  pain  — is  it  constant  or  paroxysmal,  and 
what  is  the  nature  of  the  paroxysms  ?  Before  proceeding  further 
I  must  make  here  the  followmg  observation :  while  the  examina- 
tion, as  stated  above,  is  being  conducted,  information  must  not 
only  be  collected,  but  also  made  as  clear  to  the  mind  as  possible  ; 
it  is  not  sufficient  to  learn  the  existence  of  certain  morbid  con- 
ditions ;  we  must  at  the  same  time  endeavor  to  find  theii'  cause, 
at  least  the  proximate  one.  The  nearer  we  come  to  an  explan- 
ation of  the  latter,  the  clearer  to  one's  mind  become  the  data 
obtained  by  examination,  the  easier  and  more  fruitful  is  this 
exammation.  It  is  self-understood,  that  such  a  procedure  is 
more  possible  for  an  experienced  physician  than  for  a  beginner: 
but  the  latter  will  soon  gain  the  experience,  if  he  but  acquire 
th'e  habit,  instead  of  simply  collecting  facts  mechanically,  to 
classify  the  gathered  information,  to  look  for  the  causes  and 
thus  prepare  valuable  material  for  the  erection  of  an  organic 
whole  —  the  diagnosis  of  the  whole  morbid  condition.  It  is  of 
course  also  necessary  at  the  same  time  to  acquire  a  certain  tact 
in  such  attempts  at  immediate  elucidation  of  the  matter,  so  that 
the  once  established  order  of  examination  is  not  mterfered 
with :  if  a  few  questions  suffice  to  make  clear  the  nature  of  the 
morbid  phenomenon,  then  an  immediate  explanation  of  it  is 
not  only  desirable,  but  even  obligatory  ;  but  if  it  become  neces- 
sary to  multiply  the  number  of  questions,  and  enter  further 
and  further  into  the  inquiry  about  the  condition  of  organs  not 
yet  examined,  and  even  into  the  history  of  the  past,  —  then  we 
must  postpone  the  explanation  of  the  phenomenon  until  we 
shall  have  collected  all  the  information,  i.  e.  until  after  our  full 
examination.  Attention  and  exercise  on  the  part  of  both  the 
student  and  the  instructor  will  result  in  the  speedy  acquisition 
of  the  above-named  tact. 

Let  us  now  resume  the  question  of  headache.  There  is 
hardly  a  morbid  phenomenon  which  is  so  frequent  and  brought 


—  16  — 

about  by  so  many  and  so  various  causes  as  the  unpleasant  sen- 
sations in  the  head:  pain  and  heaviness.  Morbid  conditions  of 
the  soft  parts  of  the  head  and  of  the  bones  of  the  skull  and 
face,  of  the  numberless  nerves  of  the  head,  of  the  organs  of  the 
higher  senses,  and,  the  most  important  of  all,  of  the  cerebrum 
itself,  which,  outside  of  disturbances  of  its  own  substance, 
reflects  in  itself  in  various  ways  the  influence  of  disturbances 
of  other  parts  of  the  organism,  —  these  are  all  causes  of  fre- 
quent headaches  and  heaviness.  If  the  picture  of  the  morbid 
phenomenon,  as  seen  from  the  above  necessary  questions,  points 
directly  to  some  certain  disease  (as,  for  instance,  migraine, 
masked  malaria,  syphilis,  etc.),  and  if  the  completed  part  of  our 
examination  —  and  this  latter  will  have  been  finished,  if  con- 
ducted in  a  certain  order,  by  the  time  we  reach  the  inquiries 
about  the  headache  — -  contains  data  that  may  be  considered  as 
the  causative  agents  of  the  pain  in  the  head,  then  we  certainly 
should  make  inquiries  verifying  our  assumption.  Otherwise  we 
must  leave  the  explanation  to  the  end  of  our  investigation,  al- 
though it  may  happen,  especially  with  an  inexperienced  practi- 
tioner, that  he  will  traverse  almost  the  whole  region  of  pathol- 
ogy, before  he  will  have  found  the  causation  of  the  pain  in  the 
head. 

16.  Vertigo.  If  present,  find  whether  accompanied  by  a 
flushed  or  pale  face,  by  an  overloaded  stomach  or  other  dys- 
peptic phenomena,  by  constipation,  before  hsemorrhoidal  bleed- 
ing, before  menstruation  or  after  it,  by  ursemic  manifestations, 
etc. 

17.  Paiiis  in  the  neck.,  spine,  and  extremities.  If  present, 
localize  them  (in  the  articulations,  along  the  bones,  nerves  and 
muscles),  and  determine  their  character  :  constant,  aggravated 
by  pressure  (in  the  arthrites,  periostites  and  perichondrites,  neu- 
lites  and  myosites),  or  of  an  opposite  nature  (as,  for  instance, 
lancinating  pains  in  tabes)  ;    aggravated  or  not  at  night,  etc. 

18.  Panxsthesice  and  anoesthesice. 

19.  The  nervo-miuscular  apparatus:  condition  of  muscular 
strength,  disturbances  of  locomotion,  condition  of  reflexes, 

20.  Sight  and  hearing. 

21.  G-eneral  integument:  abnormal  dryness  of  the  skin,  oj' 
sweating,  itching,  eruptions. 


—  17  — 

Anamnesh  (av6.fjLvr](n<i^  from  dva,  again  and  /ai/avt^o-kciv,  c«ZZ  fo  mind 
—  a  recalling  to  iniiicl).  Tlie  information  obtained  from  the 
patient  concerning  liis  present  condition  will  serve  as  a  guide 
in  conducting  the  mquiry  concernmg  his  past :  we  must  inform 
ourselves  of  the  history,  of  the  origin,  course  and  treatment  (if 
there  was  an}*)  of  those  departures  from  the  normal  health,  the 
presence  of  which  was  elicited  while  inquiring  about  his  present 
condition.  We  must  naturally  also  mquire  about  ailments 
which,  as  the  patient  thmks  (and  often  wrongly  so),  have  no 
comiection  with  his  present  disease.  We  also  uiform  ourselves 
at  this  stage  of  the  health  of  the  parents  and  relatives  m 
general. 

Havmg  learned  the  patient's  past  and  present  condition,  we 
invite  him  to  add  anything  he  may  desire  to  the  physician's  in- 
quiries. It  is  rarely  that  a  patient  will  fiud  it  necessary  to  add 
anythmg  after  a  physician's  thorough  questioning. 

Objective  investiyation.  Palpate  the  head  (if  necessary)  ;  in- 
spect, palpate,  percuss  and  auscultate  the  chest;  mspect. 
percuss,  and,  what  is  most  important,  palpate  the  abdomen : 
inspect  and  palpate  the  neck,  back  and  extremities ;  examine 
the  excreta,  chiefly  the  urme  (quantity,  specific  gravity,  color, 
sediments,  reaction,  presence  or  absence  of  abnormal  con- 
stituents) and  the  sputum,  and  at  times  the  mtestmal  excreta 
and  the  gastric  contents  ;  examme,  if  necessary,  the  blood ;  de- 
termme  the  temperature  of  the  body ;  mstitute  a  special 
examination,  if  necessary,  of  the  organs  of  sight  and  hearmg ; 
of  the  larjTix,  of  the  urinary  bladder,  etc. 

Examination  of  the  patient  serves  as  the  basis  for  the  diag- 
nosis, prognosis  and  treatment.  Followmg  the  method  as 
above  outlmed,  the  physician  need  not  fear  that  he  may  fail  to 
observe  or  may  omit  anythmg  of  importance  for  these  medical 
auns.  But  I  must  also  warn  you  against  another  possible  mis- 
take —  that  of  hunting  for  superfluous  details,  and  mmecessary 
mmuteness  m  mvestigatmg  both  the  present  and  the  past  con- 
ditions of  the  patient.  Not  everythmg  by  far,  obtainable  by 
investigation,  is  necessary  or  important  for  our  medical  aims  ; 
we  must  especially  distmguish  the  diagnostic  from  the  semiotic 
aims :  not  everythmg  interestmg  to  the  semiotician  is  necessary 


—  18  — 

to  the  diagnostician.  It  is  important  that  the  begmner  acquire 
the  requisite  tact  m  his  examinations,  so  as  to  avoid  f atigumg 
himself  and  his  patient ;  and  to  preserve  the  energj-  which  is  so 
necessary  in  arriving  at  serious,  sober  and  therefore  correct  con- 
clusions, he  must  leave  out  mmecessary  and  mmute  details,  as 
well  as  everythmg  that  is  confusmg  and  superficial.  The  full 
possession  of  such  a  tact  is,  of  course,  only  a  question  of  time 
and  experience ;  but  at  the  same  time  a  regular  clmical  teach- 
ing, free  from  confusion,  superficiality  and  excessive  mmuteness 
of  detail  m  mvestigation,  without  deviating  from  its  direct  aim, 
will  midoubtedly  assist,  by  its  example,  m  acquuing  this  tactful 
habit.  —  If  the  patient's  condition  be  such  that  an  examination 
of  it  will  be  difficult  or  even  pamful  to  him,  —  as  m  cases  of 
great  weakness,  heemoptysis,  dyspnoea,  cough,  pams,  etc.,  then 
we  must  ask  the  most  necessary  questions,  such  as  he  himself 
will  be  able  to  answer,  and  so  formulate  them  that  a  word  or 
even  a  sign,  positive  or  negative,  will  sufficiently  answer  them. 
For  other  uiformation  Ave  look  to  the  people  surrounduig  the 
l^atient.  They  are  naturally  the  ones  to  turn  to  m  cases  of  loss 
of  consciousness.  It  is  self-understood,  that  the  objective  ex- 
ammation  m  such  cases  must  be  conducted  with  the  utmost 
care  and  must  mclude  only  what  is  very  essential.  The  contin- 
uous improvement  m  the  condition  of  the  patient  offers  us  the 
opportmiity  to  fill  in  the  gaps  m  the  mvestigation. 

II.  Diagnosis. — It  is  a  mistaken  idea,  that  a  diagnosis  is 
arrived  at  onl}^  after  the  investigation  has  been  completed,  as  if 
this  latter  were  but  a  mechanical  process  of  collecting  uiforma- 
tion m  a  certam  order.  On  the  contrary,  as  we  have  endeavored 
to  prove  above,  the  process  of  investigation  is  a  very  active, 
searching  conditon  of  mmd :  the  data  obtamed  by  mquiries  and 
objective  examination  are  bomid  to  create  certain  suppositions 
in  the  mind  of  the  j^hysician ;  these  he  endeavors  to  prove  by 
verif3"mg  questions  and  objective  investigations,  observmg  at  the 
same  time  due  moderation,  so  as  not  to  allow  himself  to  be 
carried  away  beyond  what  he  has  ah-eady  obtamed  nor  change 
the  order  which  he  decided  to  follow.  Thus  the  diagnosis  is 
being  continuously  evolved  ivhile  the  mvestigation  is  gomg 
on,  so  that  in  the  majority  of  cases,  after  the  latter  will  have 


—  19  — 

been  concluded,  we  only  have  to  sum  up  the  total  and  we  get  a 
complete  diagnosis,  i.  e.  that  of  the  principal  disease  (^diagnods 
morhi),  as  well  as  that  of  the  secondary  disorders  and  of  all  the 
peculiarities  of  the  patient  (diagnosis  cegri).  Less  frequently, 
in  cases  which  do  not  seem  to  be  clear,  or  m  complex  cases,  we 
must  resort,  after  the  mvestigation  is  gone  through  with  and  its 
sum  total  is  made  up,  to  another  special  process  —  to  the  so- 
called  differential  diagnosis,  or  diagnosis  by  exclusion(i^zV<^;/!6i.s-/.s- 
different ialis  sen  diagnosis  per  exclusionem^  ;  in  this  we  analyze 
in  turn  all  the  suppositions  that  have  arisen  concernmg  the 
nature  of  the  given  morbid  phenomena,  and  throwmg  aside 
the  less  probable  ones,  we  retam  what  is  most  probable. 

III.  Prognosis.  Diagnosis  is  a  conclusion  based  on  the 
present ;  prognosis  is  a  presupposition  of  the  future  based  on  the 
diagnosis,  referrmg  to  the  course  of  the  disease,  to  the  changes 
to  be  expected  at  first  and  later  on ;  to  the  termination  of  the 
disease :  whether  restoration  to  health,  complete  or  partial,  or 
death ;  to  the  nature  of  the  effects  of  the  j)rescribed  treatment. 
While  followmg  the  course  of  the  disease,  we  verify  the  sup- 
positions, we  verify  the  i^rognosis.  It  is  thus  evident  how  im- 
portant the  prognosis  is  for  the  physician ;  the  more  correct  the 
prognosis,  the  stronger  it  is  verified  l)y  further  observations,  the 
more  self-confident  Ijecomes  the  physician,  the  less  wavering 
he  is,  and  the  more  positive  he  acts ;  i.  e.  the  nearer  he  comes  to 
bemg  a  truly  practical  worker,  a  practical  physician. 

None  the  less  important  is  the  prognosis  as  regards  the 
patient  and  his  immediate  people  and  relatives.  The  im- 
portance of  a  correct  prognosis  m  the  hospital  is  as  nothing 
compared  to  that  m  private  practice :  the  reputation  of  and  the 
confidence  m  the  physician  depends  on  a  prognosis  which  is 
correct,  faithful  and  m  accordance  with  the  course  of  the  dis- 
ease. It  is  hardly  necessary  to  enlarge  on  the  painful  position 
of  the  practitioner  m  whom  the  patient  reposes  no  confidence ; 
and  worse  even  is  the  condition  of  the  patient,  if  m  a  small  com- 
munity, m  the  absence  of  any  other  physician,  he  is  compelled 
to  take  treatment  at  the  hands  of  such  a  physician.  I  there- 
fore consider  it  my  duty,  and  the  duty  of  every  clinical  teacher, 
to  explain  in  each  given  case  the  prognosis  not  only  as  regards 


—  20  — 

.the  patient,  but  also  his  relatives,  altliougli  in  the  clinic,  or  in 
the  hospital  in  general,  these  last  are  absent.  I  will  here  also 
make  a  few  general  remarks  concernmg  the  value  of  the  prog- 
nosis for  the  patient  and  for  his  friends. 

As  regards  the  patient.  You  must  always  remember  that, 
with  very  few  exceptions,  those  affected  with  a  serious  ailment 
are,  by  the  fact  of  the  presence  of  the  morbid  condition  itself, 
in  an  oppressed  mental  state  and  look  rather  gloomily  and  with 
but  little  hope  into  the  future.  For  the  very  sake  of  succeed- 
ing with  his  treatment  the  physician  must  infuse  hope  into  the 
patient,  promise  a  complete  return  to,  or  at  least,  in  accord  with 
the  case,  an  improvement  of  his  health,  callmg  his  attention  to 
those  favorable  signs  in  the  patient's  condition  which  the  latter 
in  his  despair  fails  to  see  or  appreciate.  Quite  frequently  such 
an  mtentional  assurance  will  induce  the  much  needed  sleep 
which  was  absent ;  and  it  certainly  needs  no  explanation  to 
comprehend  the  importance  of  a  quiet  sleep  fOr  the  functional 
activity  of  the  nervous  system  and  through  it  of  the  whole  organ- 
ism. Nor  is  this  the  only  result  of  the  change  from  an  oppressed 
mental  condition  into  a  cheerful  one ;  if  we  but  keep  m  mmd 
the  facts  relatmg  to  the  phenomena  of  what  is  known  as  sug- 
gestion, we  will  easily  perceive  that  here  the  prognosis  coin- 
cides with  the  treatment.  But  to  apprise  the  patient  of  all  the 
apprehensions  arismg  in  the  physician's  mmd  is  always  a  blunder 
on  the  part  of  the  latter,  and  sometimes  even  a  crime  :  m  danger- 
ous cases,  where  the  least  significant  influence  may  decide  one 
way  or  another  (at  times  either  death  or  a  complete  return  to 
health,  as,  for  mstance,  in  the  stage  of  collapse  m  acute  pneu- 
monia), to  strengthen  or  to  weaken  the  patient's  courage- — 
may  bring  fatal  consequences.  I  may  add  that,  followmg,  as 
I  do,  the  above  outlined  plan  as  a  rule,  I  find  that  it  will  assist 
the  physician  in  requiring  of  the  patient  a  strict  adherence  to 
the  prescribed  measures,  disobedience  being  threatened  with  a 
change  for  the  worse. 

But  it  may  be  asked,  what  will  be  our  conduct  m  those  cases 
where  the  patient  directly  puts  to  us  the  questions  about  the 
prognosis  of  the  malady,  desiring  an  answer  because  of  the 
necessity  of  arranging  his  worldly  aifairs  and  of  fulfilling  his 


—  21  — 

religious  duties  ?  Let  us  take  au  extreme  case :  there  is  no 
lioj)e  for  prolongiiig  life,  the  end  is  approaching.  In  such  a 
case,  our  reply  must  be  to  the  effect  that  there  need  be  no  con- 
nection m  the  patient's  mind  between  the  approaching  dissolu- 
tion and  the  necessitj"  for  arrangmg  the  affairs  and  attendmg  to 
the  religious  rites  :  the  performance  of  either  does  not  necessarilj- 
imply  a  nearmg  end ;  that  the  fulfillment  of  either  will  conduce 
to  the  patient's  quietude,  and  will  therefore  also  strengthen 
him,  and  the  physician  of  course  sees  no  hmdraiice  to  their 
being  performed.  As  to  what  regards  the  direct  answer  to  the 
question  about  death  and  its  immmence,  one  may  admit  that 
the  condition  of  the  patient  is  very  serious  (not  hopeless),  and 
at  the  same  time  pomt  out  the  possibility  on  the  part  of  the 
physician  to  err  m  regard  to  his  suppositions  m  general  and  to 
that  of  the  exact  time  of  death  m  particular.  If  those  around 
the  patient  desire  him  to  attend  to  the  requirements  of  religion 
and  his  private  affairs,  then  the  physician  must  never  put  any 
obstacles  in  their  way,  choosing  an  ojDportime  moment  m  the 
condition  of  the  patient ;  but  the  physician  is  not  the  one  to  re- 
mmd  the  patient  of  it :  the  latter  will  justly  consider  it  as  his 
sentence  of  death.  It  is  the  busuiess  of  those  around  the  pa- 
tient to  remmd  him  of  it,  they  again  pleading  the  necessity  for 
his  domg  so,  not  because  of  the  approachmg  end,  but  because 
the  fulfillmg  of  the  necessary  duty  will  exert  a  quietmg  and 
strengthening  effect  on  the  patient. 

If  the  condition  of  the  patient  is  dangerous  and  even  hopeless, 
and  neither  he  nor  his  friends  approach  the  phj^sician  with 
regard  to  the  questions  as  above,  then  it  l^ecomes  the  duty  of 
the  physician  to  opportunely  remind  them  to  settle  his  affairs 
and  attend  to  the  religious  rites,  and  through  them  the  patient 
is  made  aware  of  the  necessity  of  the  case. 

Prognosis,  as  regards  the  patient's  relatives.  —  The  responsibility 
that  rests  on  the  physician,  and  the  necessity  for  the  patient's 
friends  to  be  uiformed  of  the  true  condition  of  the  patient,  so 
that  measures  in  accord  with  it  may  be  taken,  make  it  incum- 
bent upon  the  physician  to  apj)rise  the  patient's  nearest  relatives 
of  his  condition  without  hiding  an}i:hmg.  Of  the  persons 
named,  only   those  are  to  be  informed  whose  health  will  not 


—  22  — 

materially    suffer   from    the    conmimiication    of   the    expected 
fatality. 

In  a  general  way  it  is  necessary  to  be. concise  and  precise  in 
wordmg  a  prognosis.  I  am  in  the  habit  of  employing  the  fol- 
lowing formula,  Avhicli  may  be  applicable  to  the  immense  majoi- 
ity  of  cases  :  1.  Cane  (or  condition)  of  no  serious  import,  where 
danger  is  neither  present,  nor  to  be  apprehended.  2.  Serious- 
cases,  m  which  the  danger,  although  absent  at  present,  is  liable 
to  appear.  3.  Banyerous  cases,  hut  not  hopeless  ones,  where 
danger  is  present,  but  where  there  is  a  possibility  of  a  favorable 
termination,  so  that  hopes  for  recovery  may  be  entertamed.  4. 
Hopeless  cases.  —  Thus  when  usmg  the  expressions :  "■  a  light 
(not  serious)  case,"  "  serious,"  "  dangerous,"  and  ''  hopeless  " 
one,  I  distmctly  state  what  these  expressions  stand  for. 

IV.  Treatment.  —  The  principal  rule  to  follow  m  ordering 
treatment  is  the  same  as  in  other  clinical  exercises,  namely,  the 
observance  of  a  method  and  of  a  sj^stem  of  individualization. 
The  begmner,  in  whom  clinical  exercises  failed  to  mculcate  the 
habit  of  strictly  folio  whig  this  rule,  usually  proceeds  thus :  he 
diagnosticates  the  most  striking  morbid  phenomenon  in  the 
given  case,  and  then,  either  from  memory  or  by  the  aid  of  his 
text-book,  he  selects  one  out  of  several  recommended  remedies, 
the  success  of  the  choice  depending'  entirely  on  chance.  Where- 
as, by  observing  the  rule  above  alluded  to,  we  select  a  path 
which  is  much  more  devoid  of  chance,  and  is  more  certahi ;  it  is 
both  methodical,  not  allowmg  us  to  omit  anytlihig,  and  mdivid- 
ualizmg,  makuig  promment  all  the  peculiarities  of  the  case 
and  consequently  pointing  to  the  mdications  and  contramdica- 
tions  to  treatment  indicated  by  them.  The  rule  is  as  follows : 
keepmg  m  mmd  the  identical  order  of  procedure  which  was 
observed  m  diagnosis  and  prognosis,  we  must  discuss  consecu- 
tively the  hygienic  measures,  the  remedial  means  mdicated  by 
the  diagnosticated  disturbances  of  the  digestive  and  other 
abdominal  organs  ;  then  the  indications  for  the  present  disturb- 
ances of  the  organs  of  respiration,  circulation,  etc.,  taldng  in 
disorders  found  hi  all  parts  of  the  organism ;  —  then  we  must 
see  whether  the  measures  and  remedies  mdicated  by  disorders 
in    certam    organs    are  not  contraindicated  by  disturbances  of 


—  23  —    . 

other  organs,  and  then  after  considering  all  the  indications  and 
the  contramdications,  we  give  the  preference  to  the  most  im- 
portant ones,  and  out  of  several  means  recommended  for  the  chief 
morbid  condition  we  select  the  one  that  is  the  most  indicated 
and  the  least  con'tramdicated  by  the  general  condition  of  the 
organism. 

To  this  prmcipal  rule  to  be  observed  in  ordering  treatment,  I 
must  add  a  few  very  necessary  remarks  concerning  the  proper- 
ties which,  m  my  opinion,  therapy  must  possess. 

1.  The  history  of  medicine  bears  witness  to  the  fact  that  peri- 
ods of  enthusiasm  for  certain  remedies  are  succeeded  hj  periods 
of  therapeutic  nihilism.  Thhty  years  ago  I  had  the  opportu- 
nity of  witnessmg  the  decadence  of  such  a  period  of  nihilism 
in  Germany,  —  a  period,  the  beginning  of  which  may  be  traced 
back  to  the  time  and  partly  to  the  influence  of  the  founder  of 
the  so-called  homoeopathy  —  Hanneman ;  the  termination  of  this 
period  was  due  to  the  efforts  of  the  best  representatives  of 
German  medicine  —  as,  for  instance,  of  Virchow  —  who  have 
arisen  in  protest  against  therapeutic  nihilism.  At  the  present 
time,  thanks  to  the  discovery  of  a  great  many  new  and  |)artly 
very  useful  remedies,  we  observe  a  certain  enthusiasm  for 
drugs,  that  is  kept  up  by  a  still  greater,  everywhere  observed 
failing  of  medical  practice,  —  namelj^,  the  neglect  of  hygienic 
treatment.  Not  that  the  importance  of  hygiene  is  not  fully  ap- 
preciated ;  it  is,  on  the  contrary,  appreciated  better  than  at  any 
previous  jDeriod,  but  the  temptation  to  consider  our  medical 
duty  fulfilled  after  we  give  a  prescription  that  costs  so  little 
labor,  and  thus  avoid  a  thorough  hygienic  mvestigation  of  the 
case  ajid  the  medical  advice  based  thereon,  this  temptation  is 
frequently  the  cause  of  the  above-named  neglect  of  hygiene. 
Steering  between  therapeutic  nihilism  and  an  undue  enthusiasm 
for  drugs,  we  must  conscientiously  and  clearly  keep  in  mind  that 
a  true,  real,  and  not  only  seeming  medical  advice  is  one  which  is 
based  on  a  full  recognition  of  the  mode  of  livmg,  as  well  as  on 
the  history  of  the  past  and  present  condition  of  the  patient ; 
such  an  advice  embraces  not  only  the  plan  of  treatment,  but  it 
aquaints  the  patient  with  the  causes,  perpetuatmg  the  morbid 
condition  and  found  in  the  mode  of  his  livmg ;  it  makes  it  clear 


^  24  — 

to  the  j)atieiit,  that  treatment  will  only  assist  him  in  returning 
'to  health;  but  to  make  this  return  secure  the  above-named 
causes  must  be  removed.  — -  in  short,  the  patient  must  be  taught 
personal  hygiene.  I  may  as  well  add  here,  that  as  the  majority 
of  patients  are  of  weak  will-power,  it  is  the  duty  of  the  phj^sician 
to  assist  them  by  his  strength  of  character ;  and  m  prescribing 
for  treatment  and  mode  of  livmg  only  the  necessary  measures, 
he  must  msist  upon  these  latter  being  strictly  carried  out. 

2.  The  smiultaneous  employment  of  many  remedies  is  to  be 
avoided  as  much  as  possible,  especially  by  the  beginnmg  prac- 
titioner. When  one  remedy  is  being  emploj^ed,  its  effect  is 
more  prominent,  and  the  beginner  is  sooner  able  to  distinguish 
it  from  the  changes  in  the  condition  of  the  patient  not  depend- 
ent on  the  employment  of  the  drug.  If  it  becomes  necessary  to 
employ  smiultaneously  two  or  three  remedies,  then  they  must 
not  be  acbiimistered  m  one  mixture,  but  each  must  be  given 
separately,  distinctly  designating  the  time  when  they  are  to  be 
taken :  at  bedtime  (for  mstance,  to  quiet  a  cough  that  prevents 
sleep,  or  simply  as  a  somnifacient),  or  m  the  mornmg,  or  with  a 
meal,  at  certam  attacks,  etc.  We  thus  meet  the  therapeutic  in- 
dication more  exactly,  the  effect  of  the  drugs  becomes  more 
apparent  and  consequently  the  practitioner  becomes  more  ex- 
perienced in  the  application  of  the  same.  The  prescriptions  we 
frequently  see  containing  four,  five  and  more  drugs  are  posi- 
tively incorrect :  whoever  knows  that  we  must  carefully  weigh 
all  the  changes  in  the  patient's  condition  to  be  able  to  deter- 
mine exactly  the  effect  of  even  one  drug,  and  that  it  becomes 
more  difficult  to  determine  the  effect  of  two  and  especially  of 
three  simultaneously  employed  drugs,  will  understand  that  it 
is  impossible  to  determine  with  any  degree  of  exactness  the 
effect  of  a  mixture  of  a  great  number  of  drugs,  and  that  there  is 
no  reasonable  excuse  for  employing  such  mixtures,  unless  it  be 
in  exceptional  cases  and  even  then  for  a  limited  period  of  time. 
As  a  matter  of  fact,  the  number  of  old  mixtures  that  are  pre- 
served for  employment  at  the  present  time  is  msignificant  as 
compared  with  what  it  formerly  was.  The  creation  anew  of 
such  combinations  —  as  for  instance  m  the  form  of  pills  contain- 
ing   seven    ingredients,  ^ — with    our    modern    legitimate    and 


—  25  — 

necessaiy  tendencj  for  accuracy  in  medicinal  effects,  is  a  sad 
anachronism  indeed. 

3.  Hospital  therapy  is  generally  of  a  one-sided  character, 
dependmg  upon  preference  m  the  employment  of  the  apothe- 
cary's means,  ''  drugs."  Such  a  one-sidechiess,  when  m  the 
cluiic,  will  be  transmitted  to  the  students,  if  the  clmician  be 
not  careful  enough  to  avoid  such  a  defect.  It  is  therefore  the 
duty  of  the  mstructor,  —  having  first  of  all  satisfied  all  the  re- 
quirements of  the  j^atient's  personal  hygiene,  as  much  as  the 
hospital  conditions  permit,  —  to  apply  along  with  the  apothe- 
cary's means  also  all  others,  and  to  acquaint  the  students 
with  the  so-called  special  therapies :  bahieotherapy  (the  mmeral 
waters  for  dihikuig  and  bathmg  j)urposes,  hj-cbotherapy,  etc.), 
climatic  therapy,  the  employment  of  compressed  ah,  and  the 
mhalation  therapy  m  general,  electricity,  kuiesotherapy  (mas- 
sage and  gymnastic  exercises),  treatment  by  a  special  diet,  etc. : 
either  by  directly  applymg  the  named  methods  of  treatment,  or, 
in  case  it  be  impossible  to  do  so  (as,  for  instance,  m  climatic  thera- 
py), by  directmg  attention  to  the  indications  for  them  as  found 
m  the  given  diseased  condition.  If  it  is  impossible  to  require  of 
ever}'  physician,  that  he  be  as  skilled  in  the  various  special  thera- 
pies as  every  specialist  therapeutist  is  m  his  respective  specialty, 
we  can  and  must  at  least  msist,  that  every  physician  should 
know  where  and  when  to  apply  tliis  or  that  special  therapy, 
just  as  he  knows  where  and  when  to  emploj'  tliis  or  that  drug. 
Besides,  the  most  important  methods  and  applications  of 
special  therapies  are  usually  acquired  easily  by  the  ordinary 
practitioner,  as  soon  as  they  have  been  worked  out  by  the 
specialists. 

V/ Observation  of  the  course  of  the  malady.  —  It  is  self- 
understood,  that  the  duty  of  the  physician  is  not  at  an  end  after 
the  diagnosis  and  the  prognosis  are  made  and  a  plan  of  treatment 
is  laid  out :  he  must  put  this  last  uito  execution.  The  duties 
of  the  clinical  uistructor  run  along  similar  Imes :  he  must 
not  limit  himself  to  diagnosis,  prognosis  and  plan  of  treatment, 
but  must  execute  the  latter  before  his  students,  familiarizing  them 
with  all  the  dithculties  and  peculiarities  of  medical  practice  which 
become  fully  apparent  only  while   treatment   is  behig  carried 


—  26  — 

out.  With  this  in  view  the  clinical  instructor  must  impart  to 
the  students  the  art  of  observmg  the  patient,  the  knowledge  of 
comprehending  the  changes  taking  place  in  the  condition  of  the 
latter,  teach  them  to  distmguish  those  of  the  changes  which 
depend  on  the  course  of  the  disease  itself  from  those  due  to  the 
treatment,  discuss  the  results  of  this  last,  and  in  accord  with 
them  to  either  keep  on  with  the  once  outluied  plan  of  treat- 
ment, or  to  change  the  latter  m  accord  with  the  observation, 
remmduig  his  students  that  the  physician  is  but  the  minister 
naturce.  I  can  not  help  remarkmg  here,  that  the  clinicians  do 
not  often  give  due  consideration  to  the  subject  of  observation, 
although,  without  this  last,  clinical  mstruction  commenced 
and  never  brought  to  an  end  always  fails  of  its  aim,  without 
bringmg  the  benelit  that  it  could  and  should  brmg.  At  the 
same  time  it  must  be  added  that  a  certam  amomit  of  experience 
is  required  of  the  mstructor  as  well  as  due  care  m  exploitmg 
the  time  designated  for  clinical  mstruction,  which  is  always  too 
limited,  to  enable  the  clmician  to  fulfill  all  his  duties,  especially 
m  such  a  vast  clinic  as  that  for  internal  diseases ;  namely,  to 
acquamt  the  students  with  the  investigation,  diagnosis,  prog- 
nosis and  plan  of  treatment  in  typical  cases  in  all  the  branches 
of  mternal  faeclicine  as  equably  and  sufficiently  as  possible,  and 
with  this  to  fmd  time  for  familiarizmg  them  with  the  execution 
of  the  treatment,  and  with  the  observation  of  the  patient,  and  also 
to  attract  the  students  to  particij^ation  m  all  the  above-named 
exercises  and  quite  frequently  to  fill  up  the  deficiencies  in  their 
knowledge  :  of  this  we  will  speak  presently. 

VI.  The  making  up  of  the  deficiencies  in  the  information 
of  the  students  is  often  very  necessary,  because  these  latter,  on 
account  of  the  impossibility  of  observmg  a  thorough  consecutive 
ness  of  instruction,  come  to  the  clinic,  especially  at  the  begmning 
of  the  year,  without  a  sufficient  knowledge  of  certain  branches 
of  pathology,  and  more  frequently  of  therapeutics,  particularly  in 
the  domam  of  the  special  therapies.  Agam,  it  is  often  necessary 
to  inform  the  student  of  some  particularly  important  changes  or 
acquisitions  in  the  teachmg  of  that  disease,  or  of  that  depart- 
ment of  diseases,  which  is  under  observation, —  changes  and 
acquisitions  which  have  taken  place  only  very  recently,  and  which 
the  student  is  naturally  unable  to  follow  himself. 


:if;l\' 
—  27  — 

VII.  Autopsies  have  an  extraorcliuary  importance  for  tlie 
clinic,  as  an  instrument  of  progress  in  scientific  niedicuie. 
They  give  additional  data  to  tlie  ante-mortem  observations,  that 
shed  hght  on  the  matter,  thns  furthermg  diagnosis  and  general 
pathology,  and  consecj[uently  also  therapeutics.  The  history  of 
medicme  bears  evidence  to  the  fact,  that  it  wa-s  only  the  success 
of  pathological  anatomy  that  made  possible  diagnostic  progress, 
and  assists  m  the  development  of  special  pathology,  and  through 
it  of  special  therapeutics.  From  the  standpomt  of  clmical 
instruction,  the  autopsy  is  important  as  a  verification  of  ante- 
mortem  conclusions,  as  a  means  of  convincing  the  students  — 
the  future  physicians  —  of  the  jDOSsibility  of  a  correct  diagnosis, 
and  consequentl}'  of  a  correct  therapy.  Still  we  must  not  forget 
that  autopsy  is  ]jy  far  not  the  only  means  for  verifj-mg  medical 
conclusions ;  that  a  constant  verification  is  to  be  had  while  ob- 
serving the  course  and  termmation  of  the  disease.  It  would 
therefore  be  mcorrect  and  a  shii'khig  of  his  duty  —  that  of 
teachmg  diagnosis  and  treatment  of  diseases  —  if  the  clmical  m- 
structor  were  to  select  by  preference  such  cases  for  the  students 
as  would  promise  an  autopsy,  i.  e.  in  which  treatment  would  be 
230werless. 

Tlie  importance  of  the  clinic  in  scientific  medicine. — 
We  have  seen  from  the  foregomg,  that  in  the  matter  of  medi- 
cal education  the  cluiic  occupies  a  very  important  place.  No 
less  important  and  significant  is  its  role  m  medicme.  as  a 
science.  As  at  one  time  the  necessity  for  assistmg  the  sick 
created  medical  practice  and  later  medical  science,  so  at  present 
the  clmical,  that  is  the  medico-practical  activity,  continues  to 
supply  and  stimulate  medical  advance,  perfectmg  semiotics, 
diagnosis,  general  pathology  and  therapeutics,  mducmg  experi- 
mental mvestigations  aiming  to  determine  the  very  nature  of 
diseases  and  their  treatment.  As  regards  the  relation  of  the  sci- 
entific clmical  work  to  the  subject  of  clinical  instruction,  the 
mstructor,  without  cleviatmg  from  his  prmcipal  aim,  and  with- 
out loss  of  time,  can  always  embrace  the  opportmiity  of  pointmg 
out  to  the  students  the  importance  and  the  value  of  clmical 
observation  for  •  the  progress  of  medicine,  and  thus  acquamt 
them  also  with  this  role  of  the  clmic.     He  must,  however,  al- 


—  28  — 

ways  bear  in  mind,  that  his  first  duty  consists  m  cHnical  instruc- 
tion, in  educating  scientific,  practical  physicians,  and  that  a 
considerable  expenditure  of  time  on  anytliing  outside  of  clinical 
work  will  lead  to  a  premature  and  therefore  useless  diversion 
of  the  attention  of  the  unprepared  students  from  their  most 
necessary  exercises,  without  satisfymg  their  most  essential, 
requisites. 

In  concluding  the  mtroduction  to  clmical  exercise,  I  must 
say  a  few  words  regardmg  the  interrelation  between  the  work  of 
the  clinical  2^'>'ofossor,  that  of  the  clinical  assistants,  and  of  the 
students. 

The  professor  must,  first,  himself  follow  a  method  and  system 
of  individualization  m  his  clmical  work,  and  thus  mculcate  m 
the  students  habits  for  the  same. 

Secondly,,  he  must  carefully  apportion  the  time  allotted  *for 
clinical  instruction,  so  that  it  may  be  possible  to  fulfill  all  the 
duties  of  the  clinician  in  an  equable  manner.  These  duties 
have  been  defuied  above,  while  discussmg  the  observation  of  the 
patient.  As  regards,  m  particular,  familiarizing  the  students  m 
the  course  of  the  academic  year  with  the  typical  cases  m  all  the 
dejDartments  of  internal  medicine  as  fully  and  as  equably  as 
■possible,  I  must  here  mark  out  for  you  the  order  which  my  ex- 
perience, extending  over  many  years,  has  taught  me  to  consider 
as  the  best.  I  begm  the  exercises  m  the  clmic  for  mternal 
diseases  the  first  half  of  the  academic  year  (seventh  semester) 
with  diseases  of  the  digestive  organs  (stomach,  mtestmes,  liver, 
etc.),  as  they  are  the  most  important  ones,  because  of  their  fre- 
quency and- then-  comparatively  greater  curability.  As  among  the 
very  first  cases  presented  to  the  students  we  are  also  sure  to  run 
across  some  functional  disturbances  of  the  nervous  system,  these 
are  likewise  discussed  durmg  the  same  half-year.  We  at  the 
same  time  take  up  the  diseases  of  the  j)eritoneum,  the  less  im- 
portant renal  diseases  (renal  gravel  and  catarrh  of  the  renal 
pelvis)  and  gout,  which  are  so  frequently  met  with  m  diseases 
of  the  digestive  organs  and  with  which  they  are  so  closely  con- 
nected genetically.  The  second  half  of  the  academic  year  (eighth 
semester)  is  taken  up  with  diseases  of  the  organs  of  respiration 
and  circulation  (their  causation  and  partly  their  diagnosis  is  some- 


—  29  — 

what  familiar  to  the  students  from  the  propcecleutical  clmic), 
and  also  with  the  more  serious  renal  diseases  (as  mflammations, 
degenerations,  etc.).  Syphilis  of  the  internal  organs  is  preferably 
taken  up  the  first  haK-year,  because  of  the  frequency  of  syphilis 
of  the  liver.  The  acute  mfectious  diseases,  —  as  typhoid,  typhus, 
relapsmg  fever,  malaria,  pneumonia,  acute  articular  rheumatism, 
facial  erysipelas,  etc.,  the  disturbances  of  nutrition  (diabetes,  anse- 
mise,  obesity,  etc.),  and  the  disturbances  of  the  organs  of  loco- 
motion, that  we  are  liable  to  meet  with  m  the  clmic  for  mternal 
diseases  (as  diseases  of  the  muscles  and  peripheral  nerves,  of  the 
articulations  and  bones)  —  all  these  are  taken  up  in  both  half- 
years.  It  is  impossible  to  strictly  subdivide  the  contents  of  the 
clinic  for  mternal  medicme  between  the  two  half-years,  princi- 
pally because  we  usually  meet  complex  cases,  in  which,  besides 
the  principal  disease  under  consideration,  belongmg  to  that 
part  of  pathology  with  which  we  are  occupied  in  the  given 
half-year,  there  are  other  morbid  conditions,  which,  although 
belongmg  to  the  other  haK-year,  must  be  discussed  as  fully  as 
the  prmcipal  disease,  for  the  sake  of  the  correct  mvestigation 
and  individualization  of  the  given  case.  As  regards  the  special 
therapies,  we  discuss  the  internal  use  of  mmeral  waters  m  con- 
nection with  abdominal  diseases,  the  inhalation  and  climatic 
therapy  in  connection  with  diseases  of  the  organs  of  resx^iration, 
the  dietetic  therapy  hi  abdommal  diseases  hi  connection  with 
obesity  and  failure  in  nutrition,  khiesotherapy  and  treatment  by 
electricity  in  connection  with  various  cases  ;  bahieotherapy  at  the 
end  of  the  academic  year,  in  the  course  of  which  the  students 
have  had  the  opportmiity  of  observhig  the  various  applications 
of  hydrotherapy. 

Thirdly,  it  is  the  duty  of  clhiical  mstructors  to  constantly  at- 
tract the  student  to  participation  hi  the  clhiical  exercises.  As 
far  as  objective  examination  is  concerned,  all  that  can  be  seen  and 
partly  (as  percussion)  heard,  can  usually  be  demonstrated  be- 
fore the  whole  class.  But  whatever  needs  demonstration  by 
l^alpation  and  auscultation  would  require  so  much  time  to  be 
demonstrated  before  the  whole  class,  that  it  is  impossible  to  do 
it  in  the  clinic  of  internal  diseases,  and  as  a  subject  for  histruc- 
tion,  it  belongs  to  the  propaedeutic  clmic  ;  but  I  nevertheless  con- 


—  30  — 

sider  it  necessary  to  always,  in  every  case,  afford  an  opportunity 
to  as  many  students  as  practicable,  of  personally  convincing 
themselves  tlii-ough  palpation  and  auscultation  of  the  most  im- 
portant data  —  those  on  the  presence  of  which  the  diagnosis  is 
based.  Thus  m  the  course  of  the  year  many  acquire  experience 
in  objective  exammation  under  the  supervision  of  the  mstructor 
(others  under  the  supervision  of  the  assistant,  of  which  later)  ; 
and  what  is  most  important,  the  whole  class  gams  the  conviction, 
that  the  diagnosis  is  based  on  data  obtamable  not  only  through 
investigation  by  a  skilled  physician,  but  through  that  by  a  begm- 
ning  practitioner.  In  conducting  the  inveMigatioti,  diagnosis^ 
proi/nosis  and  plan  of  treatment,  as  well  as  m  the  preliminary 
analysis  of  the  given  case  and  m  further  mvestigatuig  it,  be- 
fore I  pronounce  my  conclusion,  I  usually  look  for  the  opinions 
of  some  of  the  students,  and  m  the  cases  of  greater  difficulty  I 
turn  to  the  whole  class,  requesting  any  one  to  answer  the  ques- 
tion asked.  Such  a  procedure  not  only  attracts  the  students  to 
participation  m  clinical  exercises,  but  soon  excites  in  them  an 
interest  toward  these  last. 

The  clinical  assistants,  being  independent  and  responsible  phy- 
sicians, must  fulfill  theu'  medical  tasks,  namely,  to  conduct  the 
investigation,  diagnosis,  prognosis,  treatment  and  observation  in 
the  presence  and  with  the  participation  of  the  students  m  the 
clmic,  strictly  folio  whig  the  precepts  of  the  school  —  that  is,  me- 
thodically and  individualismg  —  thus  contmumg,  as  it  were,  the 
work  of  the  teacher,  assistmg  the  students  by  exercises  m  forti- 
fying themselves  m  the  acquisition  of  a  method  and  a  habit  of 
individualization,  and  consequently  assisting  the  clmical  mstitute 
m  perfectmg  its  aims.  The  personal  self-advancement  of  the 
assistants  —  at  times  the  future  clmical  mstructors  —  as  well 
as  the  treatment  of  the  patients  m  clmic,  gains  not  a  little  by  this. 

It  is  the  business  of  the  students,  besides  participatuig  in  the 
clmical  exercises  of  the  professor  and  his  assistants,  to  conduct 
and  describe  the  histories  of  diseases  and  to  be  on  duty  in  the 
clinic. 

How  to  conduct  the  history  of  a  disease.  —  The  history  begms 
with  the  description  of  what  was  found  on  the  patient's  admis- 
sion to  the  clinic :  the  principal  complaints,  the  conditions  and 


—  31  — 

mode  of  his  living,  the  result  of  the  investigation  into  the 
present  and  past  condition  of  the  patient.  Then  follows  the 
diary ;  namely,  the  daily  note  of  the  treatment  and  of  the  altera- 
tions in  the  patient's  condition. 

The  description  of  the  history  of  the  disease^  which  is  presented 
at  the  end  of  the  half-year  and  which,  with  the  conduct  of  the 
history  of  the  disease,  serves  as  a  certificate  of  the  student's 
diligence  m  crediting  him  with  a  semester,  embraces  everythmg 
found  at  the  prelimmary  investigation,  and  then  based  on  this  — 
the  diagnosis,  prognosis  and  plan  of  treatment,  and  finally  the 
diary  m  a  connected,  historical  statement.  In  cases  of  autopsies 
their  results  are  noted  down.  Epicritical  notices  are  desirable, 
but  not  requisite,  as  not  every  history  of  a  disease  will  present 
a  reason  for  them. 

Service  in  the  clinic  enables  the  student  to  freely  observe 
pictures  of  diseases  and  become  acquamted  with  the  application 
of  various  methods  of  investigation,  as  well  as  of  treatment  (as, 
for  mstance,  hydi^o therapy,  massage,  electrotherapy,  etc.). 


CLINICAL  LECTURES. 


CLINICAL   LECTURES. 


FIRST   CASE. 


LECTURE  DELIVERED  SEPTEMBER   I9»   J889. 

Gentlemen  :  — 

We  concluded  last  time  the  introduction  to  clinical  exercises, 
in  which  we  explained  in  what  order  the  various  departments 
of  internal  diseases  would  be  taken  up  by  us.  At  the  beginning 
of  our  clmical  work  I  present  to  you  the  first  patient.  He  has 
been  in  the  clmic  smce  last  week  (from  Sept.  13th),  and  is 
suffering  from  several  diseases.  It  is  a  complex  case,  selected 
by  me  by  reason  of  its  being  more  suitable  for  demonstration 
than  the  others  we  ha^e  in  the  clinic  at  present. 

The  patient,  a  peasant,  18  years  of  age,  when  asked  as  to 
what  ails  him,  and  lioiv  long  he  has  been  sick,  complams,  as 
you  see,  of  pains  in  the  abdomen  and  loins,  of  diarrhcea  and 
vomitmg,  dating  his  illness  from  Sept.  8th,  inst. 

Patient  is  so  emaciated,  pale  and  backward  in  stature  and 
general  growth  (he  hardly  looks  to  be,  15  years  old),  that  we 
can  scarcely  believe  that  he  was  completely  well  up  to  Sept. 
8th.  And  indeed,  when  asked  about  it,  he  replies  that  he  has 
been  ailmg  for  a  long  time,  but  began  to  feel  very  bad  since 
Sept.  8th. 

In  view  of  this,  we  must  begm,  as  we  explained  in  our  intro- 
duction, the  investigation  of  the  patient  from  his  present  condi- 
tion ;  after  this  the  interrogation  about  his  past  becomes  easier, 
and  the  anamnestic  data  more  intelligible. 

Here  is  the  information  about  the  conditions  and  mode  of 
livmg  of  our  patient  before  his  admission  to  the  clmic :  he 
lives  ill  a  village  of  the  Tversk  Government,  m  a  healthy  local- 


—  36  — 

it}',  free  from  malaria  ;  liis  dwelling  is  an  ordinary  peasant's 
.  hut ;  tlie  priv}^  is  in  the  barn  for  the  cattle,  —  not  a  very  cold 
place;  he  takes  a  hot,  steaming  bath  once  a  week,"  does  not 
bathe  in  the  sea  during  summer;  does  not  smoke,  nor  drmk 
whiskey ;  drinks  some  four  cups  of  hot,  unsweetened  tea  daily ; 
has  tliree  meals  a  day  (early  breakfast,  midday  dmner,  and 
supper),  keeps  all  the  fast-days.  His  food  consists  of  rye  bread, 
cabbage  soup,  potatoes,  occasionally  buckwheat  gruel,  and,  ex- 
cept fast-days,  meat  tliree  times  a  week.  The  patient  is  smgle, 
has  lived  the  past  year  with  his  parents,  and  does  not  work  on 
account  of  illness  and  weakness ;  ui  fact,  goes  out-of-doors  but 
little,  exercises  little,  and  keeps  his  bed  most  of  the  time.  Some 
three  years  before,  he  had  been  employed  as  an  apprentice  to  a 
^village  tailor,  living  under  the  same  conditions  as  when  at  home  ; 
but  with  the  exception  of  seven  houi^s  for  sleep  and  the  time 
taken  up  by  the  three  meals,  he  would  work  the  whole  day  in  the 
close  and  vitiated  atmosphere  of  the  peasant's  hut ;  leisure  for  a 
daily  rest  or  a  daily  walk  was  not  allowed :  this  could  be  had 
only  on  Sundays  and  important  holidays  ;  although  he  had  at  his 
disposal  seven  hours  for  sleep  wliile  workmg,  and  as  much 
time  as  he  wanted  when  livhig  with  his  famil}^  the  patient  had 
suffered  for  the  last  few  years  so  constantly  from  abdommal 
pains  that  he  can  sleep  but  three  hours  out  of  the  twenty- 
four  ;  besides,  he  sleeps  on  almost  naked  boards  (on  a  bench). 

Even  from  this  collected  mformation  a  great  deal  will  be- 
come clear. 

It  is  only  by  the  assistance  of  considerable  muscular  activity 
out  of  doors  that  such  heavy  food  as  our  patient  used  can 
be  readily  digested ;  whereas,  his  only  bodily  exercise  consist- 
ed m  this :  that  he  would  sit  a  whole  day  in  a  close  room,  m 
one  position  —  that  of  a  tailor  at  work,  —  with  l^ent  body 
and  crossed  legs,  his  left  hand  holdmg  the  garment,  while  the 
right  one  is  engaged  m  monotonously  plymg  the  needle.  Not 
to  mention  other  possible  causes,  such  conditions  alone  are 
sufficient  to  give  rise  to  a  disordered  digestion.  The  disturbed 
sleep  extending  over  several  years  has  naturally  tended  to  con- 
tmuousl}'-  undermine  his   health,    etc. 


—  37  — 

Now  as  to  the  conditions  surrounding  the  patient  m  our  clmic. 
This  latter,  as  you  are  aware,  is  situated  m  a  health}^  location, 
on  a  hill,  and  surrounded  by  an  extensive  yard  and  gar- 
den. The  ward  where  our  patient  is  placed  is  satisfactory. 
The  water-closet  is  warm.  For  the  six  days  that  he  has  been 
in  the  clmic,  he  got  daily  two  soft  boiled  eggs,  two  glasses  of 
milk,  two  glasses  of  soup  with  chicken-meat  well  mmced,  and 
one-fourth  of  a  pound  of  bread  without  the  crust.  This  quan- 
tity of  food  was  given  in  six  portions,  m  the  following  order : 
1.  At  about  8  A.M.,  two  soft-boiled  eggs  with  some  bread ;  2. 
Two-thirds  of  a  glass  of  soup  and  some  bread ;  3.  A  glass  of 
milk  and  some  bread ;  4.  Two-thirds  of  a  glass  of  soujd  with 
some  bread ;  5.  A  glass  of  milk  with  bread ;  and  6,  at  about  8 
P.M.,  two-thirds  of  a  glass  of  soup  with  a  little  bread.  For  a 
drink,  only  tea  which  is  neither  strong  nor  hot,  three  to  four 
glasses  (not  full  ones)  a  day,  unsweetened,*  for  which  two  small 
lumps  of  sugar  were  given  durmg  the  whole  day. 

For  treatment  the  patient  drank  daily  two  half-glassfuls  (a 
gla§s  contains  about  8  ounces,  or  about  16  tables2:)Oonfuls)  of 
natural  Ems  water  (Kesselbrmmen),  warmed  to  30°  R.  (99.5° 
-Fl),  the  first  m  the  mornmg,  one  hour  before  the  first  meal,  and 
the  second,  one  hour  before  the  fourth  meal  (the  second  soup)  ; 
some  five  mmutes  after  the  first  and  the  fourth  meals,  he 
took  a  tablespoonful  of  decoction  of  condurango  (3  ij  to  3  iij), 
with  five  drops  of  the  tmcture  of  nux  vomica ;  after  each  soup, 
that  is  three  times  a  day,  the  patient  was  given  a  tablespoonful 
of  strong  white  Crmiea  wme ;  he  was  given  m  the  course  of  the 
six  days,  for  severe  abdommal  pains,  codeine,  gr.  ^  -f  gr.  v  sac- 
chari  albi  per  dose.  His  abdomen  was  all  this  time  wrapped 
m  a  double  layer  of  flannel.  The  patient  himself  preferred 
lymg,  and  he  was  also  advised  to  avoid  in  any  way  becoming 
fatigued,  —  to  repose,  and  to  walk  and  sit  but  little.  Being 
literate,  the  patient  was  allowed  to  read  a  little. 

Status  to-day,  September  19,  1889.  —  Appetite,  very  poor  on 
l^atient's  admission  into  the  clinic,  is  somewhat  better  now ;  his 
former  thirst,  although  not  great,  has  disappeared.  Tongue, 
somewhat  dry  on  admission,   is  now  normal.      Teeth  healthy; 

*  The  sugar  is  bitten  off  with  each  sip  of  tea. 


—  38  — 

swallows  freely.  Before  admission,  he  always  suffered  from  a 
constant  feeling  of  heaviness  and  pain  at  the  pit  of  the  stomach, 
which  would  become  aggravated  considerably  after  eatmg,  when 
there  would  appear  bel  clung  of  gases  and  of  sour  liquid,  with  a 
f  eelmg  of  burnmg,  as  well  as  nausea,  and  lately  almost  constant 
vomitmg.  The  ejecta  usually  contamed  a  moderate  quantity  of 
the  gastric  contents ;  at  one  time  some  blood  (of  this  latter  in 
the  anamnesis)'.  The  pams  and  heavmess,  as  well  as  the  belch- 
mg  and  heartburn,  have  how  considerably  dimmished ;  nausea  is 
rare,  and  there  has  been  no  vomitmg  smce  his  sojourn  m  the 
clmic.  On  his  admission  the  patient  had  loose  bowels,  some 
four  to  five  movements  a  day,  little  at  a  time  (about  a  glassful 
for  2-i  hours),  watery,  mixed  with  mucus,  but  of  normal  color 
and  without  blood.  For  the  last  two  days  the  patient  had  two 
movements  a  day  (the  whole  quantity  for  one  day  also  about  a 
glassful),  less  watery  and  without  mucus.  He  had,  on  admis- 
sion, frequent  paroxysms  of  severe  pain  in  the  abdomen  every 
day,  also  at  night,  accompanied  often  by  rumbling,  and 
relieved  by  a  movement  of  the  bowels  or  by  emission  of  gas  per 
anum.  These  pains  are  at  present  of  rarer  occurrence  and  much 
less  severe.  We  observe  no  icteric  phenomena,  nor  does  the. 
patient  acknowledge  any  m  the  past.  Emptymg  of  the  bladder 
takes  place  regularly;  quantity  of  urine  1400  cc.  m  24  hours; 
spec.  gr.  1.014,  of  a  strong  acid  reaction  and  pale  color;  when 
fresh  it  is  limpid,  but  soon  becomes  turbid;  microscopic  exami- 
nation has  shown  this  turbidity  to  consist  exclusively  of  crys- 
tals of  oxalate  of  lime,  with  some  verj-  few  epithelia  of  the 
urmary  bladder  and  a  residue  of  sodium  urate ;  albumen  and 
sugar  absent.  Condition  of  genitatia  normal;  no  history  of 
either  coitus  or  masturbation. 

Asked  as  to  whether  he  suffers  from  any  other  pams  in  the 
abdomen  besides  the  constant  pams  we  know  of  at  the  pit  of  the 
stomach,  aggravated  by  eatmg,  and  the  severe  paroxysms  of  pams 
all  over  the  abdomen  (evidently  of  intestmal  origm),  the  patient 
informs  us  that  there  is  a  constant  severe  pam  to  the  left  of  the 
umbilicus,  that  is  mtensified  by  riding  m  a  jolting  wagon  (an 
ordinary  peasant's  vehicle),  and  is  radiatmg  mto  the  left  grom 
and  mto  the  loms ;  also  some  pain  m  the  chest  (patient  points 


—  39  — 

with  his  hand  to  the  lower  lialf  of  the  sternum  and  the  adjacent 
portions  of  the  anterior  surface  of  the  chest).  This  pain,  as  it 
appears  from  investigation,  coincides  m  time  exactly  with  the 
pain  at  the  pit  of  the  stomach ;  it  too  is  aggravated  by  eatmg, 
and  it  has  also  diminished  smce  the  patient's  sojourn  in  the 
clinic ;  it  depends  most  likely  on  the  same  cause :  disease  of 
the  stomach.  The  pain  in  the  left  half  of  the  abdomen  is 
evidently  referable  to  the  left  kidney,  but  may  certainly  depend 
also  on  disease  of  the  descenclmg  portion  and  sigmoid  flexure 
of  the  colon. 

When  resting,  the  patient's  respiration  is  21  to  24  per  minute  ; 
pulse  normal  (was  weak  on  admission,  stronger  now),  rate  65 
to  70 ;  movements,  and  especially  rising,  mduce  dyspnoea  and 
palpitation.  Patient  has  never  expectorated  any  blood,  does  not 
cough  now,  and  cannot  recollect  that  he  has  ever  suffered  from 
cough,  any  throat  trouble,  or  a  prolonged  coryza. 

As  mentioned  above,  the  patient  is  very  pale  and  thin  (his 
weight  on  admission  amounted  to  91  lbs.).  He  is  also  very 
sensitive  to  chills.  Febrile  phenomena  are  absent :  temperature 
lowered— 36.4  to  36.6°  C.  (97.5  to  .97.9°  F.)  ;  the  tendency  to 
sweating,  from  which  he  suffered  while  at  home,  has  disap- 
peared ;  the  urine  is  pale,  pulse  not  frequent,  appetite  is  im- 
proving. 

He  slept  before  admission  not  more  than  three  hours  a  day ; 
now  he  enjoys  six  or  more  hours  of  quiet  sleep,  thanks  to  the 
diminution  of  the  pains,  partly  to  the  wme  and  the  more  com- 
fortable bed. 

Condition  of  mind,  much  oppressed  on  his  admission,  is  now 
more  spirited ;  there  are  positively  no  signs  of  a  morbidly  ex- 
aggerated mental  impressiveness  ("  nervousness  ")  ;  on  the  con- 
trary, the  patient,  as  you  see,  is  ver}"  quiet,  reserved,  and,  we 
must  add,  to  judge  from  his  answers,  very  sensible. 

He  suffered  before  admission  from  headaches  and  vertigo ; 
these  have  considerably  diminished  and  are  relieved  now,  as 
could  be  expected,  by  better  sleep  and  improved  circulation 
(pulse  became  stronger). 

Asked  about  the  pains  m  the  back,  the  patient  replies  that 
the  whole  back  aches,  but  particularly  the  loins  (he  puts  his 


—  40  — 

hand  on  tlie  lumbar  regions  of  the  spme  and  the  adjoming 
lateral  parts).  As  the  pams  are  mcreased  not  only  by  ridmg 
m  a  joltmg  carriage,  but  also  by  any  movement  of  the  trunk, 
they  pomt  not  only  to  the  kidneys,  but  also  to  the  motor 
agencies  of  the  spine  (bones,  muscles  and  ligaments).  The 
objective  exammation  gives  us  a  clearer  idea  of  the  localization 
of  the  pam.  There  is  no  pain  m  either  arms  or  legs,  —  their 
movements  are  free ;  Ijut  the  patient  is  very  weak  and  easily 
fatigued.     Sight  and  hearing  are  normal. 

Anamnesis.  —  It  would  be  very  desirable  to  be  informed  of  the 
condition  of  health  enjoj^ed  by  oui*  patient's  parents.  The  pa- 
tient, I  must  say  agam,  is  so  pale  and  emaciated,  is  so  puny  and 
backward  m  his  physical  development,  that  one  finds  it  difficult, 
without  further  verification,  to  ascribe  these  ]3eculiarities  solely 
to  the  recent  mfh-mities,  to  which  the  so  numerous  and  so 
promuient  abdommal  symptoms  pomt.  One  can  not  help  thmk- 
uig  that  his  generally  weak  condition  and  the  local  disorders 
may  be  but  an  expression  of  a  general  cause  (such  a  cause  is 
most  frequently  syphilis  or  tuberculosis) ;  is  the  patient  a  vic- 
tim of  hereditary  syphilis  or  does  he  come  from  a  tuberculous 
family?  On  inquiry,  as  you  hear,  we  find  that  his  parents  are 
alive  and  enjojmig  good  health;  i.  e.  they  do  not  ail  generally 
and  particularly  from  any  chest  troubles  (they  suffer  neither  from 
cough  nor  from  any  difiiculty  m  breathmg).  Out  of  a  family 
of  seven  children,  five  died  m  childhood ;  those  remaming  mclude 
himself  and  his  younger  brother,  who  is  not  ailing.  We  can, 
however,  arrive  at  no  positive  conclusions  from  this  information ; 
the  fact  that  out  of  seven  children  five  died  may  lead  us  to  sus- 
pect syphilis,  if  it  were  not  for  the  considerable  mortalit}^  of  chil- 
dren, which  is  unfortunately  of  ordinary  occurrence  amidst  the 
deplorable  circumstances  surrounding  the  life  of  the  peasant. 

The  patient  himself  has  no  recollection  of  having  been  sick 
until  his  fourteenth  year,  but  remembers  that  he  was  neither 
thin  nor  weak.  When  fourteen,  he  was  apprenticed  to  a  vil- 
lage tailor.  Of  the  severe  life  with  the  latter  we  have  already 
spoken.  After  two  years  of  such  a  life  his  health  began  to 
fail :  there  appeared  belchmg,  heartburn,  nausea,  heaviness  at 
the  pit  of  the  stomach,  and,  later,  pain  that  kept  contmually  m- 


—  41  — 

creasing ;  also  vomiting,  at  first  rare,  tlieii  more  frequent ; 
difficult  stool;  patient  grew  emaciated,  became  weak  and. sleep- 
less. After  another  year's  work  in  such  a  condition,  patient 
became  very  thm  and  very  weak,  had  to  give  up  work  altogether, 
and  over  a  year  ago  (in  May,  1888)  returned  home,  where, 
although  idle,  he  still  lived  under  much  the  same  chcumstances 
as  before,  without  any  treatment,  so  that  his  health  was  not  at 
all  improved  for  this  last  year.  Some  six  weeks  ago  his  former 
constipation  gave  place  to  diarrhoea,  —  slight  at  the  begmnmg. 
Eleven  days  ago,  September  8th,  the  patient  havmg  eaten  some 
mushrooms,  cabbage  and  cucumbers,  he  soon  experienced  severe 
pains  in  the  region  of  the  stomach,  then  there  set  m  profuse  vom- 
iting of  a  dark -colored  mass  (the  first  and  only  time),  that 
resembled  snuff  dissolved  in  water,  and  somewhat  later,  accom- 
panied by  acute  pains  in  the  abdomen,  he  had  some  six  loose 
stools  of  the  color  of  tar  (indicates  the  possibility  of  the  presence 
of  blood  m  the  evacuations  ijer  os  and  per  anum).  Smce  then, 
and  up  to  the  time  he  entered  the  clmic,  September  13th,  he 
suffered  contmuously  from  daily  vomiting,  diarrhoea  and  aggra- 
vatmg  pains  at  the  pit  of  the  stomach  and  hi  the  abdomen 
generally.  He  does  not  recollect  the  exact  time  when  he  first 
felt  pams  generally  in  the  back  and  particularly  m  the  loms,  as 
well  as  m  the  abdomen  to  the  left  of  the  umbilicus,  but  thinks 
it  must  be  long  ago. 

It  were  now  time  to  enter  upon  the  fuial  objective  examination 
of  the  patient ;  but  the  lecture  is  at  end,  and  without  finishmg 
this  exammation  and  establishing  a  final  diagnosis,  I  must  take 
up  the  treatment  of  the  patient ;  I  must  also  explain  the  neces- 
sity for  such  a  procedure  m  certain  cases  in  clinical  teaching. 
The  case  before  you  is  the  first  that  we  examine  jomtly,  and 
besides,  as  far  as  can  be  seen  already,  it  is  a  complex  one.  To 
judge  by  the  mformation  obtained  we  must  expect  disturbances 
of  various  parts  and  functions  of  the  organism :  of  the  stomach, 
intestmes,  kidneys,  of  nutrition.  Either  of  these  two  circum- 
stances (the  more  so  when  both  together)  necessitates  a  lengthy 
prelimmary  analysis  that  would  require  many  lectures ;  and  as 
we  have  but  three  lectures  a  week,  it  would  take  us  too  long 
to  complete  our  prelimmary  analysis.     The  patient,  meanwhile. 


—  42  — 

cannot  be  left  without  treatment :  this  last  begins  from  the 
time  he  enters  the  hospital,  so  that  considerable  changes  may 
have  taken  place  in  the  condition  of  our  patient  by  the  time  we  fin- 
ish our  extensive  examinaition.  Let  us  assume,  that  he  will  im- 
prove, will  regain  his  health,  will  be  cured ;  what  profit  can  you 
derive  from  the  fact  that  /was  able  to  cure  the  patient,  if  you 
yourselves  will  not  acquire  the  skill  to  do  it,  if  you  will  not  be 
constantly  informed  as  to  how  such  a  desirable  consummation 
was  attained,  and  if  you  will  not  follow  with  me  the  treatment 
and  learn  why  we  use  certain  remedies,  and  why  we  replace 
them  with  or  add  others  to  them,  as  the  changes  in  the  condi- 
tion of  the  patient  may  demand?  I  therefore,  in  such  cases, 
conduct  simultaneously  the  analysis  of  the  patient  and  the 
course  of  treatment,  and  devote  one  part  of  each  lecture  to  a 
contmuation  or  conclusion  of  the  primary  analysis,  and  the  other 
to  observation,  that  is,  to  the  discussion  of  the  changes  that 
take  place  and  to  the  direction  of  a  further  course  of  treatment. 
It  is  true  that  without  arriving  at  a  positive  diagnosis  it  is 
impossible  to  fully  explain  just  why  a  certain  course  of  treatment 
is  to  be  adopted.  But,  as  you  know  from  my  introduction  to 
clinical  work,  and  as  you  see  it  verified  in  this  case,  a  diagnosis 
is  arrived  at,  not  immediately  at  the  end  of  the  mvestigation, 
but  gradually  while  this  is  being  conducted ;  if  we  have  not  as 
yet  established  a  positive  diagnosis,  we  nevertheless  can  not  say 
that  nothing  in  the  condition  of  the  patient  is  clear  to  us. 
This  enables  me,  with  the  aid  of  the  information  obtamed  by 
you  from  the  systematic  study  of  internal  diseases,  to  gradually 
acquamt  you,  although  at  first  not  fully  so,  with  the  treatment 
adopted  even  before  the  conclusion  of  the  primary  analysis,  and 
thus  to  attract  your  participation  from  the  very  beginning  in 
such  an  important  matter  for  you  as  conducting  treatment  and 
investigation.  The  farther  we  advance  in  our  primary  analysis 
and  generally  in  our  familiarity  with  the  case,  the  easier  will 
such  a  method  of  teaching  become  ;  some  such  method,  however, 
is  mevitable.  From  my  long  experience,  I  will  add  here,  that 
such  a  method  is  not  only  free  from  inconvenience,  but  is  indeed 
useful ;  the  teacher  must  at  times  repeat  himself  —  repeat  the 
same   subject  twice ;  but  first,  such  a  repetition  is   usually  a 


—  43  — 

more  lucid  explanation  of  the  subject,  and  forms  an  addition  to 
one's  knowledge  ;  and  secondly,  a  repetition  of  those  impressions 
and  mformation  most  important  for  the  practical  physician  — 
that  should  always  be  fresh  m  his  mind  —  will  result  in  this, 
that  all  the  impressions  and  information  will  not  be  superficial 
and  ephemeral,  but  will  implant  themselves  lastmgly  in  the 
memory  of  the  students.  It  is  well  understood  that,  when  in 
analyzmg  the  patient's  condition  the  plan  of  treatment  will  have 
been  discussed,  all  the  gaps  will  be  filled,  and  whatever  could 
not  be  clearly  understood  m  the  begmning  will  be  explamed 
then. 

When  beginnmg  the  discussion  of  the  treatment,  as  well  as  the 
hygiene  of  the  patient,  we  must  first  explain  to  you  what  has 
already  been  done  for  him  smce  his  admission  into  the  clinic,  and 
what  has  already  produced,  as  you  have  heard,  a  perceptible 
improvement  m  the  patient's  condition.  It  is  hardly  necessary 
to  explam  the  importance  of  a  satisfactory  habitation,  a  warm 
water-closet,  and  of  flannel  around  the  abdomen  of  a  patient 
subject  to  acute  abdominal  pams  and  diarrhcjea ;  also  that  he  was 
given  food  often  and  a  little  at  a  time,  —  almost  exclusively  of  a 
semi-liquid  nature,  and,  I  may  add,  lukewarm  (tea,  milk,  soups, 
everything  at  the  temperature  of  freshly  drawn  milk).  I  shall 
speak  however,  more  fully  later  on  of  such  an  important  subject 
in  any  disease,  —  and  especially  for  our  patient,  —  as  diet.  You 
understand  the  indication  for  codeine  for  pain.  The  chief  indi- 
cation for  the  wme  was  the  feebleness  of  the  heart's  action  as 
evidenced  by  the  weak  pulse  and  by  dizzmess  ;  besides,  the  wme 
he  got  was  strong  and  not  sour,  such  being  useful  m  diarrhoea. 
I  will  also  remmd  you  that  the  rapid  combustion  of  the  alcohol 
of  the  wme  in  the  blood  protects  from  combustion  the  tissues 
of  the  body,  thus  checkmg  the  tendency  to  exhaustion.  To  be 
sure,  such  effect  is  inconsiderable,  in  view  of  the  small  quantity 
of  wme  the  patient  gets ;  but  taking  into  consideration  his  ex- 
treme emaciation  and  the  impossibility,  on  account  of  disease 
of  the  alimentary  organs,  of  rapid  improvement  in  nutrition, 
even  such  a  trifling  advantage  is  not  to  be  neglected. 

I  will  not  stop  at  this  moment  to  explam  the  indication  for 
the  Ems-Kesselbrunnen  mineral  water.     I    know,    from   years 


—  44  — 

of  experience,  that  the  students  attending  the  clinic  are  in- 
formed theoretically,  by  their  text-books,  that  such  and  such 
waters  are  used  in  such  and  such  diseases ;  while  the  systema- 
tic study  of  mternal  pathology  teaches  them  that  for  such  and 
such  diseases  such  and  such  waters  are  ordered;  but  I  also 
know  that  they  are  completely  at  sea  as  regards  the  clinical,  that 
is,  the  practical,  part  of  balneotherapy  —  lacking  as  they  do  the 
ability  to  select^  for  a  given  case,  from  several,  often  many,  waters 
recommended  for  a  certain  disease,  the  one  most  suitable  for 
the  case,  as  well  as  the  technical  skill  in  the  use  of  such  mineral 
waters  (how  much  and  at  what  times  to  be  taken,  etc.).  But  then 
I  consider  it  the  duty  of  the  clinician  to  familiarize  the  stu- 
dents with  this  subject ;  and  therefore,  from  almost  the  very 
beginning  of  my  clinical  practice,  appreciating  highly  the  great 
importance  of  mineral  waters  as  an  agent  of  gastric  therapy,  — 
and  not  of  that  alone  either  —  I  have  considered  it  my  duty  to  see 
to  it  that  the  students  acquire  skill  in  selecting  mineral  waters, 
and  that  they  become  accustomed  to  their  practical  use.  With 
this  in  view  I  utilize  the  first  case,  which  presents  an  indication 
for  the  use  of  mmeral  waters ;  but  such  a  case  must  be  clear 
in  all  its  peculiarities,  and  must  be  fully  diagnosticated.  Thus 
only  after  having  established  a  positive  diagnosis  and  plan  of  treat- 
ment will  I  be  able  to  show  you  the  indication,  in  our  present 
case,  for  mineral  waters,  —  for  Ems-Kesselbrunnen  m  particu- 
lar, —  its  quantity  and  the  time  of  its  admmistration  (one  hour 
before  meals,  etc.).  Once  this  elucidation  is  made  and  some- 
what extended  by  suitable  examples,  no  difficulty  will  present 
itself  in  explaining  the  indication  for  mineral  waters  m  other 
cases  that  we  may  come  across. 

The  decoction  of  condurango  and  the  tincture  of  nux  vomica 
are  not  to  be  compared  with  the  mineral  waters  in  their  impor- 
tance ;  but  their  use  will  be  fully  explained  in  the  complete 
course  of  treatment  later  on. 

It  remains  for  us  to  designate  the  treatment  for  to-day.  The 
undoubted  and  equable  improvement  of  all  the  symptoms  m  the 
condition  of  the  patient  pomts  to  a  correct  course  of  treatment, 
and  it  will,  therefore,  be  adhered  to  without  alteration ;  but  in 
order  the  sooner  to  put  an  end  to  the  abdommal  pains  and  the 


—  45  -- 

diarrlicBa,  ^yllicll  produce  a  depressing  and  weakening  effect  on 
the  patient,  I  shall  replace  the  codeine  with  a  stronger  prepara- 
tion, —  namely,  the  tincture  of  opium  (tine,  opii  simplex,  5 
di'ops  in  case  of  more  or  less  severe  pains)  and  a  warm  bath ;  — 
not  quite  a  warm  one,  a  lukewarm  bath  will  rather  tend  to 
aggravate  the  diarrhoea,  consequently  also  the  pams ;  a  hot 
bath  may  weaken  the  patient,  whose  heart  is  abead}'  weak. 
As  we  aim  to  relieve  the  pams  and  the  diarrhoea  without  weak- 
enmg  the  patient,  he  will  be  given  a  bath  that  will  produce  m 
liim  a  feeling  of  agreeable  warmth.  In  the  determination  of 
the  temperature  of  such  a  bath  we  are  guided  by  the  foUowmg : 
the  more  exhausted  and  the  more  sensitive  to  chills  the  patient 
is,  the  higher  must  be  the  temperature  of  the  bath  to  produce 
the  sensation  of  agreeable  warmth ;  if  this  sensation  is  mduced 
in  a  healthy  man  by  a  bath  of  the  temperature  of  27  to  28°  R. 
(92.7  to  95°  ^.),  then  a  sensitive  patient  will  requne  one  of 
29  to  30°  R.  (97.2  to  99.5°  F.)  and  higher.  AVe  Avill  order  for 
our  patient  a  bath  of  29°  R.  (97.2°  F.^  so  that,  m  case  he  feels 
chilly,  we  may  be  able  to  at  once  raise  it  to  a  higher  tempera- 
tui-e  by  addmg  some  hot  water. 


LECTURE  OF  SEPTEMBER  20,  1889. 

The  jjatienfs  condition.  The  gastric  and  mtestmal  pains 
were  relieved  (opium  was  needed  onlj*  once),  but  he  had  one 
loose  stool;  there  is  also  less  pain  in  the  back.  The  bath  at 
29°  R.  (97.2°  F.)  did  not  seem  comfortably  warm  to  the 
patient,  but  when  its  temperature  was  raised  to  30°  R.  (99.5°  F.^ 
he  felt  well  and  remamed  m  it  for  ten  mmutes.  Was  some- 
what weak  after  the  bath,  but  slept  well  —  longer  (seven 
hours)  and  sounder  than  before.  Feels  himself  generally 
better  to-day. 

Let  us  now  turn  to  the  unfinished  part  of  our  joint  mvesti- 
gation  of  the  patient,  to  the  objective  exammation.  The  re- 
sults of  this  are  as  follows : 

Inspectio7i  of  the  whole  body.  —  On  the  back  we  find  the  charac- 
teristic scaly  eruption  of  pityriasis  versicolor,  the  microscope 


-   —  46  — 

shows  the  presence  of  the  parasite  m  the  scales  causing  the 
eruption  (microsporon  furfur),  so  generally  met  with  in  ema- 
ciated persons,  and  particularly  m  those  suffermg  from  or  pre- 
disposed to  tuberculosis.  Extreme  emaciation ;  skin  thm,  with 
almost  no  subcutaneous  fat.  Cervical,  axillary  and  inguinal 
glands  normal. 

Qhest  —  fiat  and  generally  poorly  developed ;  scapula3  stand 
out.  Percussion  and  auscultation  elicit  nothmg  abnormal  in 
the  respiratory  organs,  the  heart  and  the  great  thoracic  arteries. 

Abdomen^  on  inspection^  seems  to  be  sunken,  and  equallj^  so 
on  all  sides,  also  m  the  region  of  the  stomach  (at  the  pit  of  the 
stomach  and  ui  the  left  hypochondrium). 

Palpation  of  the  abdomen.  —  I  must  first  make  a  few  remarks 
concernmg  the  method  of  palpating  the  abdomen,  as  I  practised 
it  before  you,  and  as  I  usually  do  it,  without  gomg  into  a  par- 
ticular discussion  of  this  method  of  investigation,  which  is 
the  busmess  of  the  propaedeutic  clmic,  i.  e.  of  practical  semio- 
tics. Palpation  of  the  abdomen  must  be  conducted  with  the 
utmost  care,  so  as  not  to  cause  harm  to  the  patient  nor  obtain 
misleading  data,  and  not  to  mduce,  by  roug'h  manipulation, 
pam  in  localities  where  there  is  none.  I  will  also  add  that 
abdomuial  palpation  should  be  practised  as  uifrequently  as 
possible,  as  even  the  most  careful  examuiation  may  react  un- 
favorably on  the  patient;  and  moreover,  the  less  frequent  the 
palpation,  the  more  appreciable  become  any  changes  ui  the  data 
obtamed  by  this  method  of  mvestigation.  I  first  determine  the 
presence  or  absence  of  cutaneous  hyperaesthesia.  I  then  proceed 
to  palpate  the  patient  as  he  is  usually  seen,  ui  the  lymg  position, 
on  the  back,  at  first  on  the  median  part  of  the  abdomen,  from  the 
ensiform  cartilage  down  to  the  os  pubis,  then  laterally  from  the 
hypochondrium  to  the  ingumal  region.  I  always  make  a  double 
palpation — first  superficially,  and  afterwards  a  deep  one  down 
to  the  posterior  wall  of  the  abdomen  if  possible.  From  the  data 
obtamed  by  such  a  method  of  examination  (always  obligatory,  if 
the  inquuy  as  to  the  condition  of  the  abdomen  demands  it) 
it  may  be  learned  whether  it  is  necessary  to  resort  to  other 
means,  such  as  palpation  of  the  abdomen  with  the  patient  in 
the  lateral  or  in  any  other  position,  or  to  some  special  method 


—  47  — 

of  palpation.  I  would  also  remark  that  in  the  case  of  a  doubt- 
ful, not  clearly  defined  tenderness  to  pressure  in  some  part  of 
the  abdomen,  I  palpate,  for  comparison's  sake,  the  correspond- 
mg  locality  on  the  opposite  side,  so  as  to  avoid  a  possible  error 
that  may  be  caused  by  an  unequal  pressure.  I  palpate  the 
diseased  side  somewhat  more  lightly  and  the  healthy  side 
somewhat  stronger.  If  this  should  indicate  a  greater  tender- 
ness on  the  former,  there  is,  of  course,  no  doubt  of  its  presence 
there. 

I  will  now  recapitulate  the  data  obtained  by  palpation  : 
cutaneous  h}'percesthesia  absent ;  quite  strong  compression  of 
the  folds  of  the  skin  m  various  parts  of  the  abdomen  do  not 
cause  any  pain;  patient  says  he  feels  the  forcible  squeezing,  but 
experiences  no  pam.  From  the  upper  edge  of  the  liver  and 
spleen,  located  while  percussmg  the  chest  and  by  the  palpation 
of  both  hypochondria,  it  becomes  apparent  that  the  dimensions 
of  these  organs  are  normal.  The  kidneys  are  inaccessible  to 
palpation,  either  with  the  patient  in  the  lying  or  in  any  other 
position.  The  region  of  the  spleen  is  not  sensitive  to  pressiu-e 
(pressure  under  the  left  margm  of  the  ribs  causes  no  pain). 
There  is  considerable  tenderness  in  the  region  of  the  stomach 
(it  was  stronger  on  his  admission)  and  some  tenderness  on  the 
side  of  the  liver,  sharply  defined  by  the  region  of  the  gall- 
bladder ;  the  remaining  portions  of  the  right  hypochondrium 
are  not  tender.  Takmg  mto  account  all  these  data,  together 
with  the  dyspeptic  symptoms  learned  by  interrogating  the  pa- 
tient, and  the  simultaneous  relief  of  these  symptoms  and  of  the 
pain  in  the  region  of  the  stomach,  we  must  accept  the  stomach 
as  the  seat  of  this  pain,  and  not  the  left  lobe  of  the  liver.  As 
you  will  recollect,  we  found  on  inquiry,  that  the  patient  had 
severe  intestmal  pams,  which  have  now  diminished.  Palpation 
has  shown  the  region  of  the  descending  colon  and  of  the  sigmoid 
flexure  to  be  sensitive,  while  that  of  the  caecum  and  of  the 
ascending  colon  were  not  sensitive  —  a  good  sign,  indicating,  in 
the  presence  of  diarrhoea,  of  a  frequent  desire  to  defecate,  and 
of  mucus  m  the  evacuations,  a  simple  catarrh  of  the  large  m- 
testine.  Tuberculous  ulcerations  of  the  intestmes,  which  one 
might  suspect  in  view  of  the  extreme  emaciation  of  the  patient, 


—  48  — 

his  weak  constitution  and  the  eruption  already  mentioned,  are 
usuall}^  located  at  the  termmation  of  the  small  and  the  begin- 
nmg-  of  the  large  mtestuies,  thus  causing  tenderness  in  the  right, 
and  not,  as  m  our  patient,  in  the  left,  iliac  region.  In  the 
other  portions  of  the  abdomen,  that  correspond  to  the  position 
of  the  intestines,  there  is  no  sensitiveness  on  palpation.  There 
is,  to  be  sure,  some  very  slight  tenderness  along  the  median 
line  of  the  abdomen,  but  it  must  evidently  be  referred  to  the 
abdommal  aorta,  which  is  surrounded  by  a  network  of  nerves, 
as  the  paui  is  felt  by  the  patient  only  along  the  course  of  that 
artery,  and  only  when  its  pulsation  is  perceptible  through  pal- 
pation. This  sensitiveness  to  palpation  in  the  vicinity  of  the 
abdominal  aorta  is  of  conunon  occurrence  m  exhausted  and 
irritable  subjects,  as  our  patient  had  become  from  long-contm- 
ued  insomnia.  Thus  also  the  considerable  pamfulness  on  the 
left  side  of  the  abdomen,  which  is  sharply  defined  by  the  locality 
of  the  left  kichiey  and  its  ureter,  is  evidently  referable  to  these 
two  organs,  and  not  to  the  mtestines,  the  more  so  because,  while 
palpatmg  the  left  kidney  from  the  front  the  patient  com- 
plams  of  pam  simultaneously  m  the  left  lorn.  Sensitiveness  on 
palpation,  although  m  a  lesser  degree,  is  also  felt  m  the  region 
of  the  right  kidney  and  ureter.  We  must  exclude  the  partici- 
pation of  the  peritoneum,  tliat  is,  the  presence  of  peritonitis,  m 
the  production  of  the  abdomuial  pams :  the  character  of  the  pains 
(which  are  neither  as  severe  nor  as  sharp  as  in  peritonitis),  the 
freedom  of  motion,  and  the  absence  of  febrile  conditions,  render 
it  improbable. 

You  may  see,  therefore,  that  a  circumstantial  uiquiiy  and  an 
exact  objective  mvestigation  make  it  possible,  notwithstanding 
the  existence  of  many  causes  for  pams  and  the  great  variety  of 
them  dependent  thereon,  not  to  be  confused  by  this  variety,  but  to 
exactly  determme  the  sources  of  the  pams,  the  affected  organs. 
As  such  we  fuid,  in  this  case,  the  stomach,  part  of  the  mtestinal 
canal,  both  kidneys  —  particularly  the  left  one  —  and  the  gall- 
bladder. 

Back.  —  On  his  admission  the  patient  complained  of  pains  all 
over  the  back,  particularly  m  the  loins,  aggravated  by  move- 
ments of  the  spine.     Objective  investigation  has  sho'svn  then 


—  49  — 

the  absence  of  liypersestliesia  cutis,  but  on  pressure  tliere  was 
tenderness  in  the  promment  bony  portions  (the  spmous  pro- 
cesses of  the  vertebrae  and  scapulae),  and  some  in  the  muscles 
of  the  spme  and  a  few  intercostal  nerves ;  directly  and  acutel}^ 
pamful  was  the  region  of  the  left  kidney,  that  of  the  right  one 
less  so.  At  present  the  patient  does  not  complain  of  pain  all 
over  the  back,  but  only  in  the  region  of  the  loins,  especially  on 
the  left  side.  By  objective  examination  we  find  absence  of 
cutaneous  hypersesthesia,  the  tenderness  in  the  bones,  muscles 
and  nerves  of  the  back  disappeared,  with  the  exception  of  some 
m  the  lumbar  region  of  the  spine,  the  motions  of  the  spine 
became  freer,  but  the  sensitiveness  m  the  kidneys,  especially 
the  left  one,  has  diminished  but  little.  Considermg  the  fact 
that  while  at  home  the  patient  slept  on  almost  naked  boards,  so 
that  his  back  was  subjected  to  almost  continuous  trauma- 
tism, and  that  with  the  removal  of  these  latter  (the  patient 
reposing  on  a  soft  bed  while  in  the  clmic)  and  with  the  im- 
provement m  his  nervous  condition,  thanks  to  a  more  quiet 
sleep,  relief  of  the  abdominal  pams,  w^arm  bath  and  the  like, 
the  pains  over  the  whole  back  have  rapidly  dimmished  and 
almost  disappeared,  —  we  must  refer  these  pains  to  the  above- 
named  external  parts  of  the  back  which  suffered  from  trauma- 
tism. We  must,  of  course,  exclude  any  affections  of  the  spmal 
cord  or  it  membranes  owmg  to  the  absence  of  any  symptoms  of 
such  affections.  The  pains  in  the  back  m  the  region  of  the 
kidneys  are  unquestionably  to  be  referred  to  the  kidneys,  as  is 
evident  from  the  data  obtamed  through  inquiry  and  objective 
exammation  of  the  abdomen. 

The  tendon,  knee  and  other  reflexes  are  normal. 

I  have  already  had  occasion  to  observe  that  the  weak  con- 
stitution and  extreme  emaciation  of  the  patient,  m  conjmiction 
with  the  pityriasis  versicolor,  excite  a  suspicion  of  the  possi- 
bility of  his  suffering  from  tuberculosis.  Of  the  organs  affected 
in  our  patient,  we  would  in  all  probability  expect  the  intestines 
and  the  kidneys  to  be  the  seats  of  tuberculosis ;  we  therefore 
had  the  faeces  and  urme  exammed  for  tuberculous  bacilli;  but 
m  neither  of  them  was  their  presence  demonstrated. 

Having  finished  our  investigation,  we  should  now  pass  over 


—  50  — 

to  the  positive  diagnostication  of  the  case;  but  m  accordance 
with  the  method  of  teaching  adopted  by  me  for  cases  requiring 
a  lengthy  discussion,  as  I  explained  last  time,  I  must  devote 
the  rest  of  the  lecture  to  the  treatment  required  by  the  condi- 
tion of  the  patient  to-day. 

We  will  certainly  not  change  the  hygienic  conditions.  Pa- 
tient's appetite  is  improvmg ;  he  would  fain  eat  more  than 
he  is  allowed ;  but  for  the  sake  of  caution  we  will  wait  another 
day  or  two  before  mcreasmg  his  quantit}^  of  food.  The  Ems 
water,  the  bitters  and  the  wine  we  will  continue  in  view  of  their 
favorable  action. 

In  the  treatment  of  the  diarrhoea  one  addition  is  to  be  made  : 
notwithstanding  the  improvement  of  other  symptoms,  the  evac- 
uations contmue  fluid;  this  is  naturally  detrimental  to  the 
condition  of  our  emaciated  patient  and  hinders  his  improve- 
ment. 

What  are  we  to  add  to  our  treatment  m  order  to  overcome 
this  difficulty  ?  If  the  evacuations  up  to  now  had  been  not  only 
fluid,  but  also  frequent  and  contamed  mucus,  —  which  would 
pomt  to  a  contmumg  catarrhal  condition  of  the  large  mtestine,  — 
then  it  were  better  to  mtroduce  some  therapeutic  means  per 
rectum  —  as  tamim  suppositories.  But  the  frequent  tenesmus 
has  ceased,  and  there  is  no  mucus  m  the  faeces ;  so  that  the 
contmuous  fluid  evacuations  point  rather  to  a  poor  absorptive 
power  of  the  small  mtestine,  dependmg,  perhaps,  on  a  catarrhal 
condition  of  the  same. 

The  mtroduction  of  remedies  i^er  anum  in  diseases  of  the 
small  mtestine  is  recommended  as  yet  only  for  special  condi- 
tions (as,  to  destroy  microbes,  to  render  ptomames  harmless,  and 
to  remove  accumulated  contents),  m  cholera,  typhoid  fever  and 
other  diseases  ;  it  remains  yet  for  practice  to  prove  the  useful- 
ness of  such  a  procedure ;  but  in  such  cases,  as  m  that  of  our 
patient,  of  an  evidently  simple  catarrh,  practice  speaks  for  the 
mtroduction  of  remedies  per  os. 

What  then  shall  we  prescribe  for  our  patient  per  os  ?  Shall 
we  increase  the  dosage  of  opium  ?  No.  Opium  is  mdicated  (al- 
ways after  a  preliminary  emptying  of  the  bowels)  m  more  acute 
cases  of  catarrh ;  the  chief  indication  for  its  use  is  uitestinal 


—  51  — 

pain.  In  chronic  cases,  where  the  uitestmal  pams  have  al- 
ready disappeared,  opium  seldom  cures  the  diarrhoea,  and  more- 
over, it  is  harmful,  masmuch  as  it  tends  to  derange  the  appetite 
and  "weaken  the  musculo-nervous  apparatus  of  the  intestmes. 
The  mtestmal  pams  in  our  patient  are  very  slight,  and  the 
appetite  is  just  beginnmg  to  improve,  while  the  nervo-muscular 
apparatus  of  the  intestines  is  very  weak,  as  is  evident  from  the 
poorly  developed  muscular  system  generally  and  the  constant 
constipation  during  the  whole  course  of  the  disease,  mitil  the 
present  diarrhrBa.  We  will,  therefore,  give  him  the  tmcture  of 
opium  as  heretofore  only  in  the  case  of  more  or  less  acute 
mtestinal  pams  which  disturb  the  patient :  five  di'ops  per  dose, 
while  for  the  diarrhfjea  proper  we  shall  prescribe  tincture  of  coto, 
at  first  m  ten-drop  doses  in  a  spoonful  of  warm  water, 
three  times  a  day,  m  the  intervals  between  meals,  and  mcrease 
the  dose  if  necessary.  Why  do  we  give  just  this,  and  no  other 
remedy?  Fnst,  in  cases  Kke  the  present  one,  tinct.  coto  has 
proved  to  be  useful,  and  I  can  testify  to  this  from  my  own  ex- 
perience ;  and  secondly,  because  in  this  case  tmct.  coto  seems  to 
be  more  suitable  than  the  other  remedies  recommended  for 
diarrhoea,  as,  for  mstance,  to  mention  the  prmcipal  ones, 
tannin,  lead  acetate,  silver  nitrate,  and  bismuth.  Tannm  and  lead 
acetate  derange  the  appetite,  while  silver  nitrate  and  bismuth 
subnitrate  are  less  reliable,  m  my  experience,  than  is  tmct.  coto. 
Besides,  the  simultaneous  use  of  mmeral  waters,  which  is 
necessar}"  for  our  patient,  as  you  see  by  the  success  attendmg 
the  treatment,  and  as  you  will  find  later  from  the  detailed  ex- 
planation of  our  therapy,  makes  it  easier  to  bear  tinct.  coto  than 
tannm  and  the  above  enumerated  metallic  salts. 

Shall  we  continue  the  warm  baths  ?  Patient  slept  particularly 
well  last  night  after  a  warm  bath — a  quiet,  soijnd  sleep.  As 
a  patient's  sleejD  is  better  the  less  the  pain  he  suffers  from,  and 
vice  versa,  we  ma}^  assume  that  the  warm  bath  has  tended  to 
relieve  the  pains  and  at  the  same  time  to  diminish  the  pathological 
processes  that  cause  these  pams.  But  experience  teaches  us 
that  a  warm  bath  may  also  brmg  about  better  sleep  m  another 
way,  —  by  changmg  the  distribution  of  blood  m  the  periphery 
of  the  body  and  in  the  internal  organs,  —  m  this  case  m  the 


—  52  — 

cerebrum :  our  patient  is  alwa3^s  chilly,  and  particularly  so  on 
sleepless  nights  ;  but  last  night  he  was  not  chilly.  The  favorable 
action  of  the  warm  bath  on  the  pains  and  on  the  sleep  is  of  the 
greatest  importance  to  our  patient,  who  has  so  long  suffered  with 
insomnia.  Without  improving  the  sleep  it  is  impossible  to  bruig 
the  nervous  system,  and  consequently  the  whole  organism,  to  a 
normal  condition.  The  good  effects  of  a  warm  bath  are  the  more 
to  be  appreciated,  as  it  does  away  with  the  necessity  for  the  in- 
ternal admmistration  of  hypnotics,  which,  besides  inducing  sleep, 
exert  other  and  even  harmful  mfluences  either  on  the  alimen- 
tary or  other  organs  or  on  the  nervous  system  itself. 

But  the  warm  bath  has  also  its  di^awbacks.  The  patient  felt 
weak  some  time  before  and  after  leavmg  the  bath ;  it  was  at  the 
same  time  evident,  from  the  feebleness  of  the  pulse,  that  the 
general  debility  was  a  result  of  weakened  hear1>action,  which 
was  manifested  quite  clearly  m  the  cerebral  circulation.  To  re- 
sort to  frequent  warm  baths,  subjectmg  the  patient  repeatedlj^ 
to  such  weakenmg  of  the  heart's  action,  temporary  and  evanes- 
cent though  it  be,  is  certainly  hardly  desirable.  Besides,  the 
frequent  use  of  the  warm  bath  may  establish  a  predisposition  to 
colds,  which  must  especially  be  taken  mto  consideration  m  view 
of  the  approaching  winter  and  the  severe  conditions  of  life  sur- 
rounclmg  our  patient.  We  will  therefore  order  for  him  baths  not 
daily,  but,  as  circumstances  may  require,  one  every  second  or 
third  day ;  we  shall  contmue  usmg  them  as  long  as  we  obtain 
favorable  results.  We  may  expect  that,  with  his  improvement, 
the  patient  will  be  able  to  bear  baths  of  a  lower  temperature, 
29°!'.  (97.2°i^.)  or  even  28° E.  (95°^.)  ;  m  case  of  his  complete 
recovery,  he  will  have  lukewarm  baths,  and  later  cool  rubbings 
to  diminish  the  susceptibility  to  cold. 

Finally,  I  consider  it  .necessary  and,  in  the  present  condition 
of  the  patient,  possible,  to  give  him  a  general  massage ;  I  say 
possible  in  his  present  condition,  because  on  his  admission,  a 
week  ago,  the  numerous  pains  were  so  severe,  so  aggravated  by 
active  and  passive  movements  (as,  for  instance,  even  when 
turned  over  very  carefully)  ,  his  sensitiveness  on  account  of  the 
insomnia  was  so  great,  that  he  could  hardly  have  borne  the 
slightest  massage.   Now,  as  you  know,  all  the  pains  have  dimin- 


—  53  — 

islied,  the  motions  are  freer,  and  there  is  a  feeling  of  comfort, 
thanks  to  the  qniet  sleep  for  the  past  week;  the  application  of 
general  massage  is  therefore  timely.  But  why  and  for  what 
purpose  ? 

General  massage  for  cases  not  exactly  like  ours,  but  simi- 
lar, was  recommended  by  the  American  physician  S.  Weir 
Mitchell,  and  gave  excellent  results.  His  observations  were 
soon  verified  and  his  method  of  treatment  was  accepted  every- 
where. I  personally  can  attest  to  its  undoubted  usefulness, 
and  in  certam  cases,  I  thmk,  it  cannot  be  replaced  by  an}-  other 
method.  The  idea  occurred  to  Dr.  Mitchell  m  connection  with 
a  case  like  the  following :  a  woman,  the  mother  of  a  numerous 
family,  exhausted  by  pregnancies,  births,  and  sometimes  b}' 
lactation,  Ijegms  verj-  decidedly  to  lose  her  health ;  the  appetite 
and  nutrition  are  impaired,  she  loses  sleep,  grows  very  thin  and 
weak ;  with  these  there  are  usually  associated  disturbances  of 
the  sexual  and  nervous  functions  :  too  frequent  and  weakenmg 
losses  of  blood  durmg  menstruation,  excruciating  pams  m  the 
head  and  back,  palpitation,  dj'spntjea,  etc.  The  usual  remedies 
such  as  arsenic,  iron,  the  Iwomides,  forced  feedmg  and  others 
—  have  no  effect,  ]3i'uicipally  because  the  household  cares  and 
the  chikben  require  mtense  physical  and  mental  activity  and 
do  not  leave  sufficient  time  for  sleep,  poor  though  it  be,  but 
tend  to  keep  up  the  disturbance  of  the  health.  It  is  in  such 
cases,  that  Dr.  Weir  Mitchell,  leaving  medicines  aside  (later, 
when  there  is  improvement  in  the  jDatient's  condition  he  admin- 
isters iron,  and  m  very  large  doses  at  that),  attacks  directly 
the  cause  of  the  disturbed  health,  the  muiatural  physical  and 
mental  exertion  and  the  fatigue  resulting  therefrom;  he  pre- 
scribes 'for  the  patient  absolute  rest  —  physical  (remauiing  in 
bed  six  weeks  at  first  without  gettmg  up  at  all)  and  mental  (com- 
plete abstmence  from  household  duties  for  the  same  length  of 
time,  and  even,  as  far  as  jDossible,  to  be  kept  free  from  all  dis- 
turbing impressions ;  when  not  bemg  given  massage,  rubbing 
and  frequent  nourishment,  the  patient  is  allowed  to  listen  to 
some  light  readhig,  but  is  not  permitted  to  read  herself).  In  the 
absence  of  physical  activity,  the  only  means  of  mducing  a  con- 
stantly good  appetite   and  sleep  —  the   first   requisites  in  the 


—  54  — 

improvement  of  nutrition  and  of  the  nervous  system  —  she  is 
ordered  general  massage. 

The  general  idea  of  Mitchell's  method  of  treatment  being 
clear,  without  gomg  mto  particulars,  for  which  this  is  not  the 
time,  let  us  turn  to  the  use  of  massage  in  the  case  of  our  pa- 
tient. We  were  to  prescribe  for  him  bodilj^  rest  —  to  rest  in  a 
lying  position,  not  only  because  any  movement  would  produce 
pam,  and  does  so  to  some  extent  even  now,  but  also  on  account 
of  his  extreme  weakness  and  fatigue.  I  may  as  well  add  here, 
that  mental  rest  is  also  secured  for  the  patient :  his  youthful- 
ness,  particularly  m  connection  with  his  sojourn  m  the  clinic, 
preclude  any  care ;  his  only  anxiety  —  about  his  health  —  we 
succeeded  in  allaying  by  promising  a  complete  restoration  of 
health.  In  the  absence  of  physical  exercise  we  will  give  him 
general  massage  over  the  whole  body  except  the  head,  the  con- 
dition of  which  presents  no  mdication  for  massage,  and  the  abdo- 
men, in  which  there  are  so  many  tender  and  painful  org-ans,  that 
even  very  careful  massage  may  cause  harm.  Besides  seciu^mg  a 
good  appetite  and  sleep,  massage  Avill  be  useful,  fu'stly,  in  di- 
mmishing  the  chillmess  of  the  patient's  body,  by  mducing  an 
equable  distribution  of  the  peripheral  circulation,  and  through 
this  of  the  circulation  of  the  rest  of  the  body ;  secondly,  by  re- 
moving the  remainmg  pams  in  the  muscles  and  other  parts  of 
the  back,  it  will  chiefly  tend  to  better  nutrition  and  to  develop 
the  muscles  and  the  other  organs  of  locomotion,  which  circum- 
stances, m  connection  with  the  general  improvement  m  his 
health,  can  not  but  exert  a  favorable  influence  on  the  future  of 
the  whole  organism :  thirdly,  by  becoming  the  means  of  remov- 
ing the  important  disturbance  of  nutrition,  as  evidenced  by  the 
oxaluria  (the  constantly  abundant  urmary  sediment  consists 
almost  entirely  of  oxalate  of  lime).  The  exact  nature  of  ox- 
aluria is  not  known,  but  its  close  relation  to  diabetes  mellitus  is 
probable ;  the  therapy  of  both  has  very  much  m  common,  and 
we  are  therefore  led  to  think  that  general  massage,  so  useful  m 
diabetes,  will  also  be  so  in  oxaluria. 

The  application  of  massage  in  our  patient  we  shall  alternate 
with  the  use  of  baths :  two  or  three  days  massage  and  then  a 
bath. 


55  — 


We  treat  the  pityriasis  versicolor  by  rubbing  the  affected 
parts  with  cotton-wool  saturated  in  a  solution  of  corrosive  sub- 
limate (1  to  1000). 


LECTURE   OF  SEPTEMBER  22,    1889. 

Condition  of  the  patient.  —  Appetite  better,  patient  begs  in- 
sistently for  more  food ;  the  dyspeptic  gastric  phenomena,  with 
the  former  quantity  of  food,  consist  only  of  a  slight  eructation 
devoid  of  pain  ;  stool  once  a  day  and  of  thicker  consistency  ; 
intestmal  pains  very  slight ;  the  pams  in  the  left  kidney  are 
dimmishing,  but  not  to  an  equal  extent.  Respiration  less  fre- 
quent (20  agamst  23  to  25  as  previously),  evidently  on  account 
of  the  diminished  abdommal  pain,  and  partly  also  because  of  a 
sounder  sleep.  Pulse,  60,  stronger  than  formerly ;  patient's 
weight  92  lbs.  (one  pound  more  than  before)  ;  sleep  better  — 
always  seven  hours  and  quietly ;  pains  in  the  back  diminished. 
He  bears  massage  very  well ;  feels  better  than  usual  at  the  time 
of,  and  a  few  hours  after  the  massage,  —  at  times  he  sleeps  for 
about  one-half  hour  after  it.  There  seems  to  be  no  call  for  a 
change  in  the  treatment,  while  the  quantity  of  food  must  be 
increased. 

Diagnosis.  —  Let  us  now  turn  to  positive  diagnostic  conclu- 
sions, while  we  follow  the  same  method  as  we  have  already 
explamecl  in  our  mtroduction  to  the  clinical  work  —  as  we  did 
in  our  mvestigation. 

I  have  already  had  occasion  to  observe  that  the  patient's 
weak  constitution  and  extreme  emaciation,  as  well  as  the 
presence^  of  pityriasis  versicolor,  excite  a  suspicion  of  tuber- 
culosis or  syphilis.  From  the  data  obtained  in  regard  to  his 
parents,  we  could  not,  as  you  will  recollect,  decide  as  to  his 
coming  from  a  tuberculous  family,  nor  was  there  foundation 
enough  for  suspecting  hereditary  S}q3hilis.  As  far  as  the 
patient  himself  is  concerned,  everythmg  contradicts  his  suffer- 
ing from  either  sypliilis  or  tuberculosis.  As  regards  the  mtes- 
tines  and  the  kidneys,  those  organs  in  which  we  would  suspect 
the  existence  of  tubercles  the  soonest,  the  careful  examination 


—  56  — 

of  the  ffeces  and  urine  for  the  nine  clays  of  his  sojourn  in  the 
clinic  failed  to  elicit  anything  to  justify  the  suspicion,  while  the 
continuous  and  comparatively  rapid  general  improvement,  as  well 
as  the  improvement  of  these  organs,  speaks  decidedly  agamst 
their  being  uivaded  by  tuberculosis.  Nothing  mdicates  the 
existence  of  syphilis :  the  hair  on  the  head,  quite  thick,  al- 
though falluig  out  a  little  m  the  course  of  the  ailment,  does  so 
on  account  of  the  patient's  lack  of  nutrition,  but  there  never 
was  a  decided  falling  of  the  hair  ;  teeth  healthy ;  outside  of  the 
pitj-Tiasis  versicolor  there  is  no  other  eruption,  nor  is  there  any 
scar  from  any  previous  ulcerations ;  there  are  no  evident  traces 
of  any  former  affection  of  the  mucous  membranes  ;  lymphatic 
glands  are  normal,  no  history  of  any  obstuiate  chronic  catari-h 
in  the  past,  nor  is  there  one  at  present ;  no  pronounced  noctur- 
nal pains  m  the  tract  of  the  tibiae  or  other  bones,  no  weakenuig 
of  the  memory. 

We  must  therefore  conclude,  that  the  patient  has  neither 
syphilis  nor  tuberculosis,  but  tlmt,  m  his  present  condition,  he 
is  predisposed  to  this  latter,  or  m  fact  to  any  other  severe 
disease,  as  for  instance,  chronic  nephritis  (m  view  of  the 
decided  oxaluria  and  the  evident  renal  colic)  and  others. 

The  Stomach.  —  This  organ,  wliich  seems  from  the  anamnesis 
to  have  been  affected  the  first  of  all,  presents  a  complete 
picture  of  a  chronic  catan4i :  there  developed  consecutively 
anorexia,  heaviness  m  the  stomach,  gaseous  eructation,  sour 
eructation  with  heartburn,  pain  m  the  stomach,  nausea  and 
vomiting,  constipation ;  all  these  symptoms  were  aggravated  by 
eatmg.  But  will  the  coincidence  of  the  gastric  symptoms  in 
our  patient  with  the  type  of  a  chronic  gastric  catarrh  be  suffi- 
cient proof  for  us  to  establish  a  final  diagnosis  of  the  latter 
without  further  discussion  ?  Certamly  not ;  first,  because  the 
disease  is  of  such  duration  and  has  so  weakened  our  patient, 
that  we  are  led  to  think  of  somethmg  more  serious  than  a 
chronic  gastric  catarrh,  especially  as  there  was  some  bloody  Voni- 
itmg,  which  does  not  occur  in  the  latter;  and  secondly,  because, 
this  being  your  first  and  withal  complex  case,  it  must  be  gone 
mto  as  particularly  as  possible,  so  that  there  may  be  a  complete 
explanation  of  all  pomts,  not  hindered  by  any  doubts  (the  more 


—  57  — 

so,  as  all  the  gastric  diseases  present  many  similar  symptoms). 
With,  this  object  in  Adew  we  will  call  m  the  aid  of  differential 
diagnosis. 

Does  not  the  patient  suffer  from  nervous  gastric  dyspepsia? 
This  may  call  mto  existence  the  same  symptons  as  a  gastric 
catarrh :  heavmess  and  pains  in  the  region  of  the  stomach,  eruc- 
tation and  heartburn,  nausea  and  vomiting.  It  chiefly  differs 
from  catarrh  ui  that  in  the  latter  all  the  above  enumerated 
symptoms  are  constant ;  whereas  m  nervous  dyspepsia,  in  uncom- 
plicated cases,  they  are  liable  to  sharp  changes  m  accord  with 
the  changes  m  the  nervous  condition  generally  (uncomplicated 
nervous  dyspepsia  is  rarely  seen  without  a  general  disturbance 
of  the  nervous  system)  ;  if  the  nervous  condition  is  not  normal, 
then  even  small  quantities  of  very  light  food  will  tend  to  produce 
the  dyspeptic  phenomena ;  but  so  long  as  the  condition  of  the 
jiervous  system  is  good,  then  even  abundant  quantities  of  heav- 
ier food  will  be  digested  without  any  inconvenience ;  besides, 
these  changes  may  occur  rapidly,  daily.  The  gastric  contents  m 
cases  of  catarrh  contain  mucus  and,  accordmg  to  the  investiga- 
tions of  our  clmical  assistant,  Dr.  Popoff,  conducted  m  the  lab- 
oratory of  Prof.  Babuchin,  also  leucocytes,  whereas  neither  is 
present  in  nervous  dyspepsia.  But  all  this  refers  to  j9wre 
nervous  dyspepsia,  which  is  not  seen  quite  often ;  if  contmued 
for  a  long  period,  it  will  become  associated  with  a  catarrhal  condi- 
tion, which  is  partly  caused  by  it.  Pure  gastric  catarrh  without 
simultaneous  symptoms  of  nervous  dyspepsia  is  observed  more 
frequently ;  but  the  most  frequent  cases  are  probably  the  com- 
plicated ones ;  viz.,  catarrh,  and  at  the  same  time,  to  a  greater 
or  lesser  extent,  nervous  dyspepsia.  The  presence  therefore  of 
mucus  'and  leucocytes  in  the  gastric  contents  mdicates  only  a 
catarrh,  but  at  the  same  time  does  not  exclude  the  possibility  of 
a  simultaneous  nervous  dyspejDsia.  Turnuig  now  to  our  patient, 
the  total  absence  of  the  above-mentioned  sudden  changeabil- 
ity in  the  gastric  symptoms,  previously  (as  I  learned  in  my 
inquiry)  and  before  us  m  the  clinic,  refutes  the  idea  of  liis 
suffering  from  nervous  dyspepsia.  Later,  when  we  come  to  ex- 
amme  the  general  condition  of  his  nervous  system,  we  will  find 
proofs  to  justify  such  a  conclusion. 


—  58  — 

Does  the  patient  have  an  atrophic  gastric  catarrh  ?  Did  not 
the  long  continued  gastric  catarrh  induce  an  atrophy  of  the 
gastric  glands,  which  would  result  in  a  diminution,  or  even  in  a 
suspension,  of  the  secretion  of  hydrochloric  acid  and  pepsin,  i.  e. 
in  the  impossibility  to  digest  albuminous  bodies  ?  The  rapid  dim- 
inution of  the  gastric  sym]3toms  in  our  patient  since  his  admission 
to  the  clinic  and  their  total  absence  at  present  while  digesting  a 
goodly  quantity  of  largely  nitrogenous  food  (as  eggs,  soup  with 
bro ken-up  meat,  milk),  speak  decidedly  against  it. 

Does  our  patient  suffer  from  gastric  cancer  ?  The  patient's 
age  and  the  long  continuance  of  his  trouble  certainly  contradict 
this  supposition,  but  still  not  unconditionally.  Cancer  is  possi- 
ble even  at  his  age ;  and  as  far  as  the  long  duration  of  the 
disease  is  concerned,  there  might  at  first  be  a  chronic  catarrh, 
while  the  cancer  could  appear  later.  But  against  cancer  sjDcak 
positively  the  same  data  as  against  atrophy  of  the  gastric 
glands :  rapid  improvement  of  the  gastric  symptoms  and  the 
unimpeded  digestion  of  a  tolerable  quantity  of  food. 

We  can  not  be  so  positive  with  regard  to  idcer  of  the  stomach. 
The  apparently  bloody  vomiting  and  the  frequently  occurring 
(especially  before  admission  to  the  clinic)  attacks  of  severe 
pains  in  the  abdomen,  accompanied  by  vomiting,  speak  for  it. 
The  fact  that  this  bloody  vomit  happened  only  once  m  the  long 
run  of  the  disease,  and  even  then  only  after  he  had  eaten  a  con- 
siderable quantity  of  mushrooms,  speaks  against  ulcer.  There 
are  known  cases  where  the  use  of  mushrooms,  as  a  food,  was 
followed  by  a  bloody  vomit.  The  attacks  of  acute  pain  in  the 
abdomen  accompanied  by  vomiting  might  be  ascribed  to  an 
exacerbation  of  the  gastric  catarrh,  and  also  to  symptoms  of 
liver  and  kidney  colic  (of  which  I  will  speak  later).  Although 
the  rapid  improvement  in  the  gastric  symptoms  and  their  absence 
during  the  digestion  of  a  goodly  quantity  of  food  do  not  speak 
as  decidedly  against  ulcer  as  against  cancer  and  atrophy  of  the 
glands  of  the  stomach,  still  they  make  the  existence  of  an 
ulcer  in  our  present  case  hardly  probable,  because  even  if  im- 
provement and  return  to  health  is  j)ossible  in  gastric  ulcer,  it 
could  not  be  so  decided  in  such  a  short  time. 

It  is  beyond  doubt,  then,  that  our  patient  suffers  from  a 
chronic  gastric  catarrh. 


—  59  — 

In  a  clironic  gastric  catarrli  the  mucous  membrane  of  tlie 
stomach  is  fomicl  to  be  hypersemic,  thickened  and  covered  with 
mucus.  As  regards  the  microscopic  appearances,  Dr.  Popoff's 
investigations  *  give  the  following  results :  there  is  observed 
everywhere  a  hyperplasia  of  the  tissues  of  the  mucous  mem- 
brane, particularly  of  the  connective  tissue,  a  mass  of  leucocytes 
and  mast-cells ;  the  epithelium  is  not  only  not  detached,  but 
is  in  a  condition  of  active  karyokinesis,  while  its  cells  are  en- 
larged and  full  of  mucus :  the  number  of  parietal  cells  is 
mcreased  and  the  process  of  karyokinesis  is  observed  m  some : 
then  there  are  a  great  many  chief  cells  and  also  a  numl^er  of 
cells  which  it  is  difficult  to  clistmguish  as  belonging  to  either 
one  or  the  other  (Nussbaum's  cells). 

As  regards  the  hydrochloric  acid  and  pepsm,  the  mvestigations 
of  Dr.  Popoff,  both  from  experiments  on  animals  and  from  obser- 
vations on  patients,  show  that  m  the  condition  of  chronic  gastric 
catarrh  these  substances  are  secreted  in  quantities  sufficient  for 
digestion,  so  that  the  peptic  (digestive)  power  of  the  stomach  re- 
mams  unimpaired,  except  at  the  period  when  fatty  degeneration 
and  atrophy  of  the  gastric  glands  have  already  begmi.  AVhere, 
then,  one  may  ask,  do  the  dyspeptic  symptoms  in  catarrh  come 
from  ?  The  causes  of  these  are  :  1.  weakened  gastric  move- 
ments, (as  evidenced  by  the  msufficient  emptymg  of  the  stom- 
ach, that  usually  occurs  in  gastric  catarrh)  which  prevent  the  food 
from  bemg  ultimately  mixed  with  the  gastric  juice  (this  may 
also  be  caused  by  the  mucus).  2.  As  Dr.  Popoff  assumes,  the 
numerous  microbes  of  the  stomach,  which  remain  m  it.  when 
the  latter  is  in  a  catarrhal  condition,  for  a  longer  time  on  ac- 
count of  bemg  surrounded  by  the  mucus  covering  the  wall  of 
this  organ,  and  also  because  of  the  sluggishness  of  the  gastric 
movements.  The  classification  and  study  of  these  microbes  m 
the  future  will  surely  shed  some  light  on  their  possible  role  in 
causmg  the  dyspeptic  j)benomena  m  gastric  catarrh,  as  well  as 
their  part  m  the  origm  of  the  catarrh  itself.  3.  Finally,  the 
addition  to  the  catarrh  of  a  nervous  dyspepsia,  —  of  possible 
changes  of  nervous  origin,  in  the  secretion  of  the  gastric  juice. 

However  that  may  be,  the  contents  of  the  stomach  in  a  catar- 

*In  liis  doctoral  thesis,  "  Catarrli  of  the  Stomach." 


—  '60  — 

rlial  condition  contain  an  abnormal  quantity  of  gases  and 
acids ;  then  there  is  besides,  as  already  observed,  an  insufficient 
emptying  of,  and  at  times  even  a  stretching  of  the  stomach  by 
the  accumulated  contents,  and  as  a  result  of  the  retarded  pas- 
sage of  the  gastric  contents  into  the  intestines,  there  is  consti- 
23ation.  This  stretching  of  the  stomach,  quite  often  met  with, 
but  usually  yieldmg  readil}"  to  correct  treatment,  must  not  be 
confounded,  as  is  often  done,  with  another,  a  much  less  frequent 
but  more  obstinate  and  difficultly  removable  condition  of  the 
stomach,  viz.,  dilatation  of  the  stomach,  as  it  is  observed,  for 
mstance,  m  diseases  of  the  gastric  pjdorus,  that  prevent  the 
passage  of  the  gastric  contents  into  the  mtestines. 

Does  our  patient  suffer,  besides  the  gastric  catarrh,  also  from 
stretching  of  the  stomach?  The  data  obtained  so  far  fail  to 
verify  this,  at  least  for  the  later  period  of  the  disease  :  neither  on 
his  admission  nor  at  present  can  we  notice  the  least  distention 
in  the  left  hypochondrium ;  the  attacks  of  vomitmg,  before  his 
admission,  with  the  catarrh  m  a  condition  of  exacerbation,  were  of 
daily  occurrence  and  the  vomitmg  non-abundant ;  whereas  m  the 
condition  of  gastric  distention,  vomitmg  is  abundant  m  quantity, 
but  of  rarer  occurrence.  But  it  is  principally  the  rapid  improve- 
ment m  the  appetite  that  speaks  against  gastric  distention,  because 
in  the  latter  condition,  as  long  as  this  distention  is  not  removed,  as 
long  as  the  stomach  is  not  enij^tied  (for  this,  lavage  is  best), 
there  is  anorexia.  You  will  observe,  that  in  discussing  the  ques- 
tion as  to  whether  our  patient  suffers  from  a  distended  stomach 
or  not,  I  do  not  mention  the  so-called  gastric  splash,  as  I  do  not 
consider  this  a  reliable  symj)tom  of  distention  of  the  stomach ; 
it  is  true  that  it  usually  accompanies  distention,  but  may  be 
found  to  take  place  also  in  the  absence  of  this  condition,  even  in 
perfectly  healthy  people  ;  it  is  even  probable  that  it  may  occur  also 
in  the  mtestmes,  at  least  m  the  large  one.  It  were  unreasonable, 
in  view  of  the  unreliability  of  such  a  symptom,  to  attempt  to 
cause  it  m  our  patient,  whose  abdomen,  including  the  stomach 
itself  and  the  neighboring  very  tender  left  kidney,  is  so  highly 
sensitive.  In  the  discussion  of  cases  which  will  present  a  thera- 
peutic indication  for  lavage,  and  which  will  later  probably  be 
brought  before  you,  I  shall  touch  also  on  the  gastric  splash. 


—  61  — 

Particular  attention  has  been  drawn  latel}^  to  the  stomach  and 
its  diseases,  to  the  mvestigation  of  the  walls  of  the  stomach,  to 
the  condition  of  its  glands  at  the  time  of  digestion,  to  the  obser- 
vations of  the  fiTst  stages  of  gastric  catarrh,  to  the  investiga- 
tion of  alterations  m  the  secretions  of  the  gastric  juice  in 
diseases  of  the  stomach  and  m  other  ailments.  As  might  be 
expected,  the  results  obtained  are  taken  advantage  of  m  perfect- 
mg  diagnosis :  not  only  is  the  matter  vomited  or  that  oljtamed 
by  gastric  lavage  (where  this  last  is  used  therapeutically)  ex- 
ammed,  —  all  this  was  certamlj"  also  done  before  ;  but  the  gastric 
contents  are  directly  obtained  with  a  view  of  examinmg  them  and 
the  introduction  of  sample  food  is  resorted  to  (^' trial  breakfast," 
''  trial  dinner  ").  This  consists  in  introducmg  mto  the  previously 
emptied  and  washed-out  stomach  food  of  a  certain  quantity  and 
quality,  and  later,  at  certain  intervals,  the  gastric  contents  are 
withdi'a'mi  and  examined :  by  the  results  of  this  mvestigation 
we  judge  of  the  peptic  power  of  the  stomach,  of  the  quality  of 
the  gastric  juice  (whether  or  not  it  contains  a  sufficiency  of 
hydrochloric  acid  and  pepsm)  and  of  the  strength  of  the  gastric 
movements  (whether  or  not  the  stomach  is  emptymg  its  contents 
regularly).  Some  msistently  recommend  such  procedures  m  prac- 
tice, and  require  their  application  almost  m  everj'^  case  of  gastric 
disease,  claiming  that  diagnosis,  without  these,  is  either  impos- 
sible, or  at  least  msufficient. 

Without  drawing  at  present  any  general  conclusions  as  to  the 
importance  of  the  above-mentioned  methods  of  investigation,  and 
the  judiciousness  of  their  being  msisted  upon  in  practice,  let  us 
see  what  data  we  might  obtain,  were  we  to  apply  these  methods 
to  our  present  case,  whose  seriousness  warrants  the  use"  of  any 
method  that  would  give  any  special  results.  If  our  patient  vom- 
ited or  if  there  were  any  necessity  for  washmg  out  his  stomach, 
then  it  would  certamly  be  singular  not  to  examme  the  vomited 
matter  or  that  obtamed  by  lavage.  But  while  m  the  clhiic  our 
patient  did  not  vomit,  and  lavage  was  not  mdicated  (why  it 
was  not,  is  partly  ajpparent  to  you  from  what  I  said  of  the  com- 
plete absence  in  the  patient  of  any  signs  of  a  distended  stomach, 
and  will  later,  in  discussing  the  treatment,  be  made  clear). 
We  consequently  would  have  to  resort  to  obtaining  the  contents 


—  62  — 

of  the  stomacli  and  to  the  expenmental  mtroduction  of  food, 
that  is,  to  the  frequent  introduction  of  the  gastric  sound.  And 
what  woukl  we  learn  by  tliis  ?  We  would  learn,  whether  the 
food  is  well  digested  or  not,  whether  or  not  the  hydrochloric 
acid  and  pepsin  are  secreted  m  sufficient  quantity.  But  we  have 
learned  this  without  the  introduction  of  a  sound,  and  moreover 
with  greater  certamty  and  without  any  mconvenience  or  harm 
to  the  patient.  By  mtroducmg  easily  digestible  food  m  small 
quantities,  we  observed  that  the  dyspeptic  phenomena  began  to 
dimmish  rapidly  and  in  a  few  days  disappeared  altogether  :  at  the 
present  time  our  patient,  having  six  meals  a  day,  not  onlj-  does 
not  observe  any  dj'speptic  symptoms  after  each  meal,  but  on  the 
contrary  soon  has  a  desii^e  to  eat  agam  —  also  a  sure  indication 
of  a  previousl}^  completed  digestive  act.  Consequently,  we  also 
mtroduced  "  trial  "  meals,  and  several  times  a  day  at  that,  and  we 
not  only  learned  that  the  secreted  gastric  juice  ls  of  normal  quality, 
and  that  normal  digestion  can  take  place,  but  we  also  constantly 
keep  under  observation  the  condition  of  the  digestion  and  its  im- 
provement, not  b}'  resortmg  to  the  contmual  mtroduction  of  the 
sound  and  to  the  investigation  of  the  gastric  contents,  —  and  how 
mconvenient  this  would  be  for  both  the  physician  and  patient ! 
—  but  by  being  guided  by  the  most  reliable  criterion,  namely,  the 
absence  of  dyspeptic  phenomena  and  the  improvement  in  the  ap- 
petite, with  which  the  data  obtamed  by  the  gastric  somid  will  stand 
comparison,  these  bemg  frequently  misleaduig  and.cjuestionable. 
Besides,  these  last  data  can  only  pomt  to  the  condition  of  the 
gastric  digestion,  and  it  would  therefore  be  one-sided  and  erro- 
neous to  judge  by  them  —  as  one  is  often  tempted  to  do  —  of 
the  condition  of  digestion  in  general,  because  dig-estion  takes 
place  not  m  the  stomach  alone,  but  to  an  equal,  if  not  to  a 
greater,  extent  also  in  the  small  mtestine. 

But  this  is  only  one  side  of  the  question ;  let  us  look  at  the 
other.  Does  not  the  introduction  of  the  stomach-tube  entail 
hardships  on  the  patient,  —  may  it  not  even  harm  him  ?  It  is 
only  after  persistent  persuasion  on  the  part  of  the  physician, 
that  patients  overcome  the  feelmg  of  extrelne  disgust  towards 
this  procedure.  As  far  as  harm  is  concerned,  not  to  speak  of 
the  unfortunate  accidents  m  the  past  that  were  due  partly  to 


—  63  — 

tlie  imperfectiiess  of  the  metliod  and  partly  on  account  of  the 
physcian's  negligence,  even  now,  with  the  most  perfect  method  and 
extreme  care,  the  introduction  of  the  sound  is  often  not  devoid  of 
harm  to  the  patient.  Thus,  in  our  patient,  in  the  presence  of  the 
exacerbation  of  the  gastric  catarrh,  wdth  which  he  was  admitted 
to  the  cluiic  (daily  vomiting  with  acute  pam),  the  introduction 
of  the  sound  might  have  caused  a  fresh  attack  of  nausea  and  pain, 
that  is,  it  might  have  aggravated  the  condition  of  the  stomach, 
that  was  just  beginnmg  to  improve  when  the  patient  m  general 
and  his  stomach  m  jjarticular  were  surrounded  as  far  as  pos- 
sible by  favorable  conditions.  This  would  take  place  m  a  catar- 
rhal condition  of  the  stomach ;  the  risk  of  mjuring  the  patient 
would  l3e  greater  still  m  gastric  ulcer  or  cancer.  The  introduc- 
tion of  the  sound,  in  cases  of  nervous  dyspepsia,  may  also 
considerably  aggravate  the  condition  of  the  patient.  More  than 
once,  at  medical  consultations,  have  I  seen  severe  cases  of  ner- 
vous dyspepsia  and  general  nervous  disturbance,  m  which  the 
proposition  to  introduce  the  sound  was  under  discussion,  —  a 
proposition  that  in  the  majority  of  cases  had  to  be  set  aside,  and 
the  patient  improved  despite  or  rather  on  account  of  its  non-intro- 
duction. It  can  not  be  denied,  that  the  thoughtless  mtroduc- 
tion  of  the  somid,  without  sufficient  reasons,  unfortunately  quite 
frequent  with  practitioners  who  are  carried  away  by  novelty 
and  fashion,  deserves  strong  condenmation. 

From  the  foregoing  it  becomes  clear  which  method  would  be 
the  more  reliable  m  determinmg  the  condition  of  our  patient's 
stomach  and  its  peptic  power,  —  the  one  that  we  have  chosen, 
creatmg  for  the  patient  and  his  stomach  jDossible  favorable  con- 
ditions, and  removmg  whatever  aggravated  the  condition  of  the 
stomach  and  made  digestion  difficult,  or  the  other,  in  which  we 
would  add  to  the  above  the  introduction  of  a  gastric  sound,  that 
might  exert  a  contrarj^  influence. 

Let  us  now  consider  the  importance  of  the  gastric  sound  in 
the  differential  diagnosis  of  our  case.  In  regard  to  the  atrophic 
condition  of  the  gastric  glands,  the  rapid  decrease  of  the  dyspep- 
tic phenomena  and  the  improvement  in  the  appetite  speak  so 
strongl}^  against  it,  as  to  obviate  the  necessity  for  using  the 
so  mid.     While  its  use  with  a  diagnostic  j)  expose  in  the  case  of 


—  64  — 

cancer  would  not  only  fail  to  give  as  good  results  as  were  ob- 
tained by  observation,  but  would  even  lead  to  vacillations  in 
the  diagnosis.  In  fact,  the  rapid  decrease  of  tbe  dyspeptic 
phenomena  and  the  improvement  in  the  appetite,  which  are  not 
to  be  thought  of  m  a  case  of  a  fully  developed  cancer  (the  pa- 
tient has  been  ailmg  for  a  long  tune),  enabled  us  to  positively 
exclude  cancer;  whereas  the  examination  of  the  gastric  con- 
tents obtauied  by  the  aid  of  the  sound,  b}^  showing  the  presence 
of  hydrocliloric  acid,  would  lead  us  to  doubt  as  to  whether  the 
case  was  that  of  a  simple  chronic  catarrh  or  whether  cancer 
might  not  also  be  present ;  for,  although  m  the  majority  of  cases 
of  cancer  the  contents  of  the  stomach  contam  no  free  hydi-ochloric 
acid,  appreciable  under  certam  color  reactions,  still  there  are 
frequent  exceptional  cases,  hi  which  the  free  acid  is  found.  In 
ulcer  of  the  stomach  the  mtroduction  of  the  sound,  not  to  speak 
of  special  risk  of  injurmg  the  patient,  would  give  notion g  of  po- 
sitive value  m  the  way  of  a  differential  diagnosis  between  thLs 
condition  and  chronic  catarrh.  As  regards  nervous  dyspej)sia, 
we  have  said  before,  that  the  complete  absence  of  sudden 
changes  in  the  local  (dyspeptic)  phenomena,  and  as  we  shall  see 
later,  the  general  nervous  condition  of  the  patient,  permitted  us 
to  j)Ositively  exclude  it  without  necessitatuig  a  supplementary 
investigation. 

But  some  will  say,  this  is  all  clear  to  me  now ;  but  how  was 
it  at  the  begmnmg  ?  In  the  beginning  it  was  only  probable,  that 
the  patient  had  a  clironic  gastric  catarrh,  and  no  other  disease 
of  the  stomach ;  but  the  pi-obability  became  stronger  every  day, 
so  that  in  a  few  days  the  probabilit}'  became  a  eertaijity.  To  be 
sure  we  had  to  wait  a  few  days ;  but  washing  of  the  stomach, 
the  introduction  of  a  "  trial  "  meal  and,  subsequent  to  this,  the 
frequent  introduction  of  the  somid,  as  well  as  the  repetition  of 
this  procedure  (which  would  be  necessary  m  such  a  serious, 
complicated  case  of  long  duration),  would  also  require  rather 
more  than  less  time,  because,  as  was  explamed  above,  observa- 
tion of  the  patient  when  surrounded  by  favorable  conditions 
only  would  clear  up  the  matter  sooner  than  if  he  were  surroun- 
ded by  both  favorable  and  unfavorable  (the  mtroduction  of  the 
sound)  conditions.  The  ^possibility  of  keepmg  the  patient  mider 


—  65  — 

observation  after  he  had  been  placed  among  favorable  circum- 
stances, the  causes  keeping  up  the  diseased  condition  having  been 
removed, while  strong  medical  agents  are  not  resorted  to  before 
the  matter  is  clear,  —  this  possibility  is  of  great  value  m  arriv- 
ing at  a  correct  diagnosis,  and  consequently,  also,  correct  thera- 
peutics, especially  in  chronic  cases. 

Now  that  we  have  considered  the  value  that  the  gastric  sound 
and  the  mtroduction  of  a  "  trial "  meal  would  have  in  our  case,  I 
can  express  my  opmion  concerning  the  importance  of  this  method 
of  investigation  in  its  present  state  for  the  diagnosis  of  gastric 
diseases  in  general ;  only  rare  cases  present  a  judicious  reason 
for  the  application  of  this  method;  it  may  be  otherwise  when  m 
the  course  of  time  the  reliability  of  the  data  obtained  by  this 
method  will  be  increased. 

To  avoid  misunderstandings,  I  will  add  that  we  must  not  con- 
found two  different  matters  :  it  is  one  thmg  to  work  out  a  new 
method,  which  is  always  a  matter  worthy  of  respect,  but  is  only  a 
question  of  the  personal  mvestigations  of  the  clinician,  and  not  a 
subject  of  uistruction  for  his  students  ;  to  these  he  must  communi- 
cate only  tried  methods,  that  deserve  to  be  applied  m  practice 
on  account  of  then  valuable  results ;  nor  must  they  be  Ijurden- 
some  to  either  patient  or  physician.  It  is  another  thing  to  pre- 
sent to  the  students  methods  that  are  mcomplete  and  may 
burden  them  with  procedures  that  offer  nothing  new  or  valuable, 
at  the  same  time  inconveniencing  the  patient  and  leadhig  to  waste 
of  time  and  energy  on  the  part  of  the  physician,  besides  distractmg 
his  attention  from  facts  that  are  important  and  yet  easily  obtain- 
able. Many  a  time  have  I  seen  the  fruitlessness  of  the  labors  of 
physicians  brought  up  under  such  influences :  such  a  physician 
would  collect  a  mass  of  minute  and  worthless  data  (not  to  speak 
of  the  present  time,  let  me  recall  the  "  titration  "  ej^idemic  of 
sad  memor}^,  the  exhaustive  exammation  of  the  ui'me,  useless  for 
practical  purjDOses,  etc.),  without  knowmg  what  to  do  with  them  : 
he  would  spend  time  and  energy  in  collecting  these  and,  not 
havmg  passed  thi'ough  a  regular  clmical  course,  he  fails  to  ob- 
serve the  simple,  patent  and  nevertheless  very  important  facts  : 
and  even  if  he  does  observe,  he  does  not  take  advantage  of  them, 
and  thu.s  remams,  until  taught  by  bitter  experience,  if  not  for- 


—  66  — 

•  ever,  a  fiiiical  seniiotician,  a  ]30or  diagnostician,  and  consequent- 
ly an  inefficient  therapeutist.  Such  a  physician  prides  himself 
on  his  "  scientific  "  method  of  practice  in  that  he  applies  the 
minutest  and  latest  results  of  mvestigations,  not  comprehending 
that  science  —  the  highest  common-sense  —  can  not  be  contra- 
dictory to  the  orduiary  reasonmg,  according  to  which  we  must 
select  from  a  great  mass  of  data  only  what  is  of  utility,  and 
must  resort  to  methods  of  investigation  that  are  really  necessary. 
I  must  remind  you  that  whatever  has  been  said  of  the  gastric 
sound  refers  to  its  use  for  diagnostic  purposes ;  its  application 
in  therapeutics,  where  it  constitutes  a  useful,  unreplaceable 
method  of  treatment,  is  a  totally  different  matter,  of  which  we 
shall  speak  later. 


LECTURES  OF  SEPTEMBER  27  AND  29  AND  OF 
OCTOBER  4,  1889. 

Patient^ s  condition  Septemher  27.  —  Former  treatment  con- 
tinued ;  the  quantity  of  food  increased :  up  to  the  2 2d  the 
patient  got  two  glasses  of  milk,  two  glasses  of  soup  with  finely 
broken  up  meat,  two  eggs,  and  about  one-quarter  pound  of  white 
bread;  but  now  he  gets  besides  these  two  glasses  of  milk- 
soitp  with  manna,  one-fourth  of  a  chicken,  and  another  one- 
quarter  pound  of  bread.  This  quantity  of  food  the  patient  takes 
m  seven  portions.  The  appetite  contmues  improvmg  and  the 
patient  craves  for  more  food.  The  only  dyspeptic  symptom  is 
slight  retchmg.  The  pains  m  the  stomach  and  on  the  side  of 
the  gall-bladder  have  disappeared  entirely :  pressure  m  these 
regions  elicits  very  little  tenderness.  Stool  —  once  a  day,  pain- 
less (smce  the  22d  he  has  been  given  the  opium  drops  only 
twice)  ;  evacuations  thicker,  not  liquid,  but  soft  and  somewhat 
formed,  without  mucus.  The  urine  is  less  pale,  with  a  smaller 
sediment  of  oxalate  of  calcium.  The  pains  in  the  kidneys,  and 
especially  m  the  left  one,  persist  as  yet  and  become  aggravated 
on  movmg  and  walkmg,  if  the  abdomen  be  not  suffiently  sup- 
ported by  the  flannel  bandage  ;  the  left  kidney  is  still  verj- 
sensitive  to  pressure.  The  pains  in  the  back  are  limited  to  the 
region  of  the  kidneys,  the  others  have  disappeared  after  mas- 


—  67  — 

sage.  Tlie  organs  of  tlie  chest  are  normal,  as  before.  For  five 
clays  tlie  patient  gained  another  pound  in  weight  (his  weight  is 
now  93  pounds).  Sleeps  quietly,  some  seven  and  one-half 
houi'S  at  night  and  one-half  hour  m  the  day-time ;  mental  con- 
dition better,  physical  weakaess  less.  The  former  headaches 
and  dizziness  absent. 

There  is  evidently  no  need  of  changing  the  treatment;  we 
must  only  increase  the  dose  of  the  tmcture  of  coto,  as  the  evac- 
uations are  as  yet  changeable,  at  times  formed,  at  others  not : 
besides,  the  patient  might  become  habituated  to  the  previous 
dose :  we  will  give  him  now  fifteen  drops  thi^ee  times  a  day  (in- 
stead of  the  former  ten).  We  will  also  add  some  cognac  to 
the  milk  —  a  teaspoonful  to  a  glass.  The  quantity  of  food  will 
be  carefully  mcreased. 

We  will  turn  now  to  the  diagnosis : 

The  diagnosis  of  the  condition  of  the  stomach  was  finished 
last  time.  We  will  only  add  to-day,  that  the  mcrease  of  the 
appetite  and  the  contmually  improvmg  digestion  tend  more  and 
more  to  verify  our  diagnostic  conclusions  concerning  the  con- 
dition of  this  organ. 

The  intestinal  tract.  —  Until  last  August  the  patient  suffered 
with  a  constant  constipation.  The  causes  of  this  might  be : 
first,  the  retarded  passage  of  the  gastric  contents  mto  the  intes- 
tmes  because  of  the  weakened  movements  which  usually 
accompany  gastric  catarrh  (the  patient  on  admission  had  no 
signs  of  dilatation  of  the  stomach,  probably  on  account  of  tlie 
constant  vomitmg  before  admission,  which  emptied  this  or- 
gan) ;  and  second,  a  weakening  of  the  nervo-muscular  activity  of 
the  stomach  and  mtestmes,  due  to  the  weakness  of  the  nervo- 
muscular  apparatus  m  general  and  to  his  sedentary  life.  Since 
Augnst  the  constipation  has  been  replaced  by  a  diarrh(jea  —  a 
sign  of  a  superadded  intestinal  catarrh.  Both  the  large  mtes- 
tme  (frequent  painful  strammg,  mucus  m  the  evacuations. 
P-tms  in  the  region  of  the  sigmoid  flexure)  and  probably  the 
small  one  (as  was  exp lamed  when  ordering  tincture  of  coto)  are 
effected  by  the  catarrh.  The  patient's  weak  constitution  and 
poor  nutrition,  as  well  as  his  pityriasis  versicolor,  excited  a  sus- 
picion of  tuberculosis  m  general,  and  of  that  of  the  intestines 


—  68  — 

in  particular,  although  the  absence  of  fever  and  pams  in  the 
ileo-coecal  region  spoke  against  it.  Repeated  exammation  of 
the  fseces  failed  to  prove  the  presence  of  intestmal  tuberculosis, 
while  the  rapid  improvement  in  the  general  condition  as  well 
as  in  the  condition  of  the  mtestines  also  positively  exclude 
it. 

The  liver  mid  the  hiliary  j^assages.  —  The  liver  presents  noth- 
ing abnormal :  the  pam  elicited  by  pressure  at  the  pit  of  the 
stomach  was  referable,  as  explamed  during  the  objective  exam- 
ination, not  to  the  left  lobe  of  the  liver,  but  to  the  stomach, 
There  is  slight  but  constant  tenderness  on  pressure  m  the  region 
of  the  gall-bladder,  pomtmg  to  some,  diseased  condition  of  the 
bladder.  Which  is  it?  From  the  data  at  hand  it  points  only 
to  biliary  calculi  m  the  bladder ;  the  slight  intensity  of  the  pains 
spealts  against  pericystitis,  while  the  entire  absence  of  swelling 
excludes  any  new  formation.  Catarrh  of  the  gall-bladder,  as 
part  of  the  general  catarrh  of  the  biliary  passages,  must  also  be 
elimmated,  on  account  of  the  absence  in  the  past  and  at  the 
present  time  of  any  symptom  of  this  condition,  namely  jaundice, 
as  a  result  of  the  obstruction  of  the  biliarj^  passages,  due  to  their 
catarrhal  condition.  There  remain  then  biliary  calculi.  Whe- 
ther or  not  our  patient  had  attacks  of  biliary  colic  brought  on, 
under  accidental  circumstances  (as  by  traumatism,  b}-  riding 
in  a  jolting  carriage,  by  faulty  diet,  mental  excitement,  cold), 
by  the  presence  of  calculi  in  the  bladder,  we  can  neither  deny 
nor  affirm.  We  have  not  observed  them  m  the  clmic ;  but  then 
every  exacerbation  and  every  attack  of  pam  ceased  in  the  clinic. 
Concernmg  the  past  history  of  the  patient  it  is  impossible  to  de- 
cide as  to  what  extent'the  attacks  of  pain  eventuating  in  vomit- 
mg  depended  on  the  exacerbation  of  the  gastric  catarrh  and  to 
what  extent  they  were  due  to  liver  and  kidney  colics.  As  re- 
gards the  last  two  diseases,  we  may  mfer,  judging  by  the  present 
condition  of  the  patient,  that  the  principal  colic  was  of  renal 
origm. 

Kidneys.  —  The  left  kidney  is  very  tender  on  pressure  ;  the 
right  one  much  less  so.  Besides,  at  home,  after  a  jolting  ride, 
and,  to  a  very  slight  extent,  in  the  clinic  after  walking,  there 
appeared  typical  attacks  of  renal  colic,  viz.,   pains   in  the  re- 


—  69  — 

gion  of  the  left  kidney,  radiating  upward  and  into  the  left  lorn, 
as  well  as  downward  into  the  left  groin  and  left  testicle.  The 
cause  of  this  is  evidently  ascribable  to  concretions  of  oxalate  of 
lime  m  the  pelves  of  the  kidneys  (nephrolithiasis),  especially  in 
the  left  one.  We  say  of  oxalate  of  linie,  because  our  patient  has  a 
typical  oxaluria :  urine  pale,  but  strongly  acid ;  on  his  admission 
it  gave  an  abundant  sediment  of  crystals  of  oxalate  of  liine,  with 
scarcely  any  uric-acid  deposit.  Further  than  this  the  kidneys  are 
not  affected :  there  is  neither  hsematuria  nor  any  catarrh  of  the 
renal  pelves,  (the  urine  contams  no  mucus,  no  leucocytes,  no 
epithelium  from  the  renal  pelvis,  nothing  but  a  small  quantity  of 
bladder  epithelium),  nor  nephritis  (albumen  and  cylmders  are 
also  absent  m  the  urine).  The  patient  himself  presents  a  typical 
oxaluric  aspect,  as  described  by  the  well-known  neapolitan  clini- 
cian, Cantani :  mental  and  nervous  oppression  (oppressed  mental 
condition  and  bodily  weakness  on  his  admission),  emaciation  in 
general  and  of  that  the  muscular  system  in  particular,  and  severe 
pams  m  the  loins.  I  will  add  that,  with  the  improvement  m  general 
and  with  that  of  nutrition  in  particular  (as  seen  by  the  gain  in 
weight),  there  was  also  observed  a  turn  for  the  better  in  the  course 
of  the  oxaluria  :  the  urme  is  now  less  pale,  and  gives  a  less  abun- 
dant sediment  of  oxalate  of  lime  crystals,  but,  instead,  more  of  the 
uric-acid  deposits  (amorphous  sodium-urate  and  even  crystals  of 
uric  acid).  Physicians  resident  at  the  mmeral  springs,  such  as 
Contrexeville,  where  so  many  suiferers  with  oxalic  acid 
nephrolithiasis  congregate,  have  observed  that,  with  the  im- 
provement in  health  m  these  patients,  a  dimmution  in  the 
oxalic  acid  sediments  in  the  urine  takes  place,  while  the  uric-acid 
sediments  mcrease  proj)ortionately.*  However,  the  improve- 
ment in  our  patient  is  only  noticed  in  the  oxaluria  as  yet ;  the 
kidney  pains  decrease  very  slowly.  Experience  has  shown  that 
the  concretions  of  oxalate  of  lime,  formed  m  the  pelvis  of  the 
kidney,  are  the  most  difficult  of  all  to  treat,  and  require  a  long 
time  before  they  disappear. 

Does  not  our  patient  suffer  from  movable  kidnej^s,  es^Decially 
the  left  one,  which  is  so  sensitive  on  motion  (although  this  symp- 

*  Debout  d'Estrees:  Des  iudications  des  eaux  de  Coutrexdville,  Paris, 
1889,  p.  8. 


—  70  — 

torn  is  also  found  with  renal  calculi)  ?  Notwithstanding  the 
patient's  extreme  emaciation  and  his  sunken  abdomen,  we  were 
unable,  while  examming  him,  to  even  once  feel  the  left  (or  the 
right)  kidney ;  however,  this  fact  would  speak  agamst  a  ma- 
terial displacement,  but  would  not  exclude  limited  mobility  of 
the  kidney,  for  the  existence  of  even  this  latter  condition  is  suffi- 
cient to  account  for  severe  renal  pains  while  in  motion  or  while 
bemg  jolted.  Considering  the  extreme  failure  of  nutrition,  the 
weakening  of  all  the  tissues  of  the  body  and  the  number  of 
traumata,  to  which  our  patient  was  subjected  (riduig  m  a 
wagon),  mobility,  especially  of  the  left,  painful  kidney,  is  very 
probable. 

Patient's  chesty  as  we  said  before,  is  poorly  developed.  The 
lungs  and  the  respiratory  tract  present  notlihig  abnormal ;  the 
heart  is  normal  except  for  the  weakness  of  its  contractions. 
The  weakness  of  the  pulse,  which  is  now  decreasing,  depends 
partly  on  the  anaemia,  partly  on  the  weakened  heart-action,  that 
accompanies  failure  of  nutrition  m  general  and  of  the  muscular 
system  in  particular. 

Nutriti07i  and  JTcematopoiesis.  We  have  pomted  more  than 
once  to  the  extreme  failure  of  nutrition  and  to  the  poor  develop- 
ment of  the  patient,  as  well  as  to  the  causes  of  these  conditions ; 
we  have  also  called  j^our  attention  to  another  important  symptom 
of  a  greatl}^  disturbed  nutrition,  namely,  oxaluria.  As  regards 
hsematopoiesis,  the  patient  certainly  presents  ansemic  symptoms 
—  a  weak  pulse,  paleness,  dizziness  with  a  pale  face,  chilliness, 
etc. ;  but  his  ansemia  is  only  a  part  of  the  general  failure  of  nutri- 
tion, and  not  an  mdependent  affection,  as  chlorosis,  pernicious 
anaemia,  leukcemia.  We  draw  this  conclusion,  first,  from  the 
complete  absence  of  any  sjmiptoms  of  the  above-named  diseases, 
and  secondly,  from  the  fact  that  neither  the  spleen  nor  the  lym- 
phatic glands  present  anything  abnormal. 

His  nervous  system^  when  he  was  admitted  to  the  clinic,  pre- 
sented, as  you  will  recollect,  the  following  abnormal  phenomena : 
poor  sleep,  dizziness,  pains  in  the  head,  back  and  abdomen, 
oppressed  mental  condition  and  bodily  weakness  —  an  aggrega- 
tion of  symptoms  which  is  usually  observed  hi  persons  suffering 
from  nervous  debility,  —  neurasthenia.     Must  we  conclude  from 


—    71     — 

this  that  our  patient  has  neurasthenia  ?  We  constantly  hear  in 
our  practice  nowadays  of  cases  diagnosed  as  "  neurasthenia," 
and  we  find  that  under  this  name  entirely  different  cases  are 
mcluded,  which  are  similar  only  in  their  nervous  manifestations, 
and  not  even  m  all  of  these.  Such  a  custom  will  eventuate  in 
the  term  neurasthenia  losing  its  distmctive  significance  and  be- 
commg  a  name  only  for  a  group  of  symptoms,  and  this  not 
always  the  same ;  whereas  m  reality  it  defines  a  certam  disease. 

Here  are  the  characteristic  features  presented  by  persons  suf- 
fering from  a  typical,  pure,  uncomplicated  neurasthenia  :  ofttimes 
they  are  men  sturdilj^  built,  long-lived,  with  perfectly  healthy 
pectoral  and  abdominal  organs  of  a  normal  (up  to  a  certam 
period)  functional  activity,  and  an  excellent  nutrition  ;  and  still 
they  are  complammg  of  nervous  disturbances,  that  at  times 
they  sleep  well,  at  other  times  poorly,  without  being  able  to  as- 
sign any  reason  for  it ;  of  a  rapid  changeability  of  the  mental 
condition  —  now  oppressed,  now  excited ;  both  their  mental 
energ}^  and  physical  strength  quickly  give  way  to  weakness. 
To  all  this  there  is  superadded  pain  in  different  parts  of  the 
body,  for  which  there  would,  at  the  painful  spots,  seem  to  be 
no  apparent  local  cause ;  also  hj^pertesthesia  cutis  and  an  in- 
crease in  the  tendon  reflexes ;  later  on  disturbances  appear  in 
the  functions  of  different  organs,  usually  first  of  all  constipa- 
tion, later  (occasionally  a  long  time  after)  nervous  dyspepsia, 
palpitation  of  the  heart,  and  other  symptoms.  Investigation  of 
the  causes  of  such  a  diseased  condition  usually  brmgs  to  light 
hereditary  predisposition, — weakness  and  susceptibility  of  the 
nervous  system  from  their  very  birth,  and  also  affections  of  the 
latter  acquired  through  the  agency  of  noxious  influences. 

Is  it  thus  with  our  patient  ?  The  poor  sleep  in  his  case  was 
not  the  result  of  unknowai  causes,  but  was  due  to  the  pams,  up- 
on the  relief  of  which  it  soon  became  normal ;  with  better  sleep 
and  with  the  improvement  of  the  pulse  (of  the  heart-action) 
the  headaches  and  dizziness  also  soon  disappeared;  the  other 
pains  were  very  clearly  traceable  to  various  diseased  conditions 
in  parts  where  they  were  felt;  our  joatient  has  neither  skin- 
hypersesthesia  and  mcreased  tendon  reflexes,  nor  any  apparent 
signs  of  nervous  dyspepsia,  nor  palpitation  of  the  heart;  nor  is 


—  72  — 

his  mental  condition  changeable ;  on  the  contrary,  he  is  very 
reserved ;  the  oppressed  mental  state  m  which  he  was  when  ad- 
mitted soon  passed  away  with  the  relief  of  the;  pams,  improvement 
in  the  sleep  and  with  the  revival  of  hope  in  our  patient ;  the 
considerable  and  slowly  disappearing  physical  weakness  is 
easily  explamable  by  the  extreme  emaciation  of  the  muscles  and 
the  unsatisfactory  development  of  the  skeleton.  Considering 
the  general  failure  of  nutrition  m  our  patient,  which  would  nat- 
urally reflect  itself  in  the  nutrition  of  liis  nervous  system,  then 
the  poor  sleep  for  a  prolonged  period  of  time,  and  the  acute  pams 
in  the  many  affected  organs  for  a  similar  period,  which  m  its  turn 
would  affect  the  nervous  system  injuriously,  and  observmg  at 
the  same  time,  how  rapidly  the  latter  improves  simultaneuosly 
with  the  general  improvement  in  the  patient's  health,  with  the 
relief  of  local  pains  and  better  sleep,  we  must  conclude,  fu"st, 
that  our  patient's  nervous  system  presents  not  only  a  particu^ 
larly  weakened  condition,  but  that,  on  the  contrary,  it  appears 
to  be  the  strongest  part  of  his  whole  organism ;  and  secondly, 
that  our  patient  has  no  real,  primar}"  neurasthenia;  that  his 
nervous  symptoms  were  developed  m  consequence  of  and 
owmg  to  diseases  of  other  organs  (witness  the  anamnesis), 
and  they  pass  away  so  quickly  with  the  removal  of  the  causes, 
that  they  evidently  disprove  the  existence  of  obstinate  neuras- 
thenia, even  of  secondary  origin. 

As  is  evident  from  the  preceduig,  the  summary  of  our  diag- 
nostic conclusions  is  as  follows  :  our  patient  has  a  clu'onic  gastro- 
mtestmal  catarrh,  that  assumed  an  acute  form  before  he  entered 
our  clmic ;  also  biliary  calculi,  renal  colic,  very  probably  a  mov- 
able left  kidney,  serious  failure  in  nutrition,  with  oxaluria',  pity- 
riasis versicolor,  a  series  of  secondary  nervous  disturbances  of  a 
passing  nature,  extreme  emaciation  of  the  muscles,  and  a  poorly 
developed  skeleton.  We  can  not  state  the  degree  of  depen- 
dence of  the  last  two  conditions  on  heredity,  as  we  know  but 
very  little  of  the  constitution  and  health  of  the  patient's  parents  ; 
but  it  is  beyond  doubt  that  at  first  the  contmuous  sitting  in  the 
position  of  a  tailor  at  work,  and  later  on  the  uninterrupted  lying- 
posture,  on  account  of  the  pams  and  weakness,  which  means  a 
contmuous  lack  of  regular  phj^sical  exercise  and  fresh  air  in  the 


—  73  — 

course  of  the  last  four  years,  in  the  period  of  adolescent  growth 
of  the  organism,  could  not  but  play  an  important  part  in  the 
development  of  the  diseased  conditions  above  mentioned. 

Progyiosis.  —  The  patient's  condition  is  serious,  that  is,  such 
(vide  Introduction  to  Clinical  Exercises)  as  not  to  present  any 
immediate  danger  to  life,  but  such  a  danger  may  arise  either 
because  the  various  affections  of  our  patient,  becoming  aggra- 
vated on  the  return  to  his  former  surroundmgs  of  life,  may 
bring  him  into  a  condition  beyond  remedial  action,  or,  rather, 
because  of  the  possible  development  in  the  exhausted  organism  of 
tuberculosis,  chronic  nephritis,  etc. ;  or  finally,  some  accidental 
cause,  such  as  a  severe  cold,  may  bring  about  a  rapidly  develop- 
mg  affection  that  may  prove  fatal  to  the  weakened  organism. 
The  diseased  conditions  of  the  patient  are  not  of  a  fatal  character 
■per  se,  and  are  curable.  Whether  or  not  they  are  easily 
curable  is  another  question :  it  must  be  apparent  even  to  you, 
beginners  though  you  be,  that  they  are  difficultly  curable 
conditions,  —  particularly  so,  if  we  are  to  apply  treatment  as 
thoroughly  as  our  science  demands  it ;  i.  e.  not  only  to  effect 
the  removal  of  local  affections,  but  also  to  improve  the  patient's 
nutrition  and  constitution,  without  which  treatment  will  be  far 
from  thorough  ;  nor  would  the  improvement  m  health  be  lasting. 
But  the  chief  difficulty  lies  m  this,  that  if  we  even  succeed  in 
removmg  the  local  disturbances  while  he  is  in  the  clmic,  m  im- 
proving his  nutrition  and  in  directmg  into  a  healthy  path  the 
future  well-being  of  the  patient,  we  must  teach  him  to  live,  as 
as  far  as  possible,  under  such  conditions  of  life,  that  he  may, 
after  leavmg  the  clinic  and  returnmg  to  the  former  unfavorable 
surroundings  of  life,  remam  m  the  possession  of  what  he  gamed 
and  thuS  strengthen  his  health  the  more. 

Such  is,  in  the  given  case,  the  physician's  view  of  the  future. 
Of  this  the  patient  must  be  informed  only  so  far  as  will  enable 
liim  to  appreciate  his  own  condition  and  his  individual  hygiene, 
in  order  to  combat  noxious  mfluences,  and  by  avoidmg  them  to 
preserve  his  health ;  but  not  so  much  of  it  as  would  discourage 
liim,  depriving  him  of  the  energy  so  essential  in  the  struggle. 

Treatment.  —  To  meet  all  the  requirements  of  hygiene  is  the 
essential  condition  of  every  successful  treatment.      You  know 


—  74  — 

by  this  time  the  nature  of  and  the  reasons  for  the  hygienic  con- 
ditions under  which  we  placed  our  patient ;  you  also  know  that, 
partly  with  a  hygienic  purpose  in  view  (to  make  up  for  the  lack 
of  exercise)  and  partly  on  account  of  certam  therapeutic  objects, 
as  already  explamed,  massage  was  ordered  for  our  patient.  It 
remains  now,  while  we  occupy  ourselves  with  the  hygiene,  to 
speak  of  the  diet. 

As  a  drmk,  the  patient  was  given  only  tea,  lukewarm,  neither 
hot  nor  strong.  Water,  especially  if  not  warmed,  would  only 
tend  to  prolong  the  diarrhoea.  Lukewarm  tea,  as  a  slightly 
astringent  drink,  is  more  suitable  for  diarrhoea.  But  tea  is  not 
only  slightly  astringent,  it  is  chiefly  a  stimulant  and  the  patient  is 
habituated  to  its  use ;  this  is  to  be  taken  into  account.  I  will  not 
enter  now  into  a  detailed  discussion  of  the  important  question,  as 
to  the  limits  to  be  permitted  by  the  physician  m  the  use  of  stimu- 
lants, as  our  case  does  not  j)resent  a  sufficient  reason  for  such  a 
discussion :  our  patient  not  only  does  not  abuse  the  most  impor- 
tant of  these,  —  wme,  brandy  and  tobacco,  —  but  does  not  use 
them  at  all.  I  will  only  observe  that,  as  the  normal  course  of  the 
nervous  and  consequently  of  the  other  functions  of  the  body 
does  not,  strictly  speaking,  require  the  aid  of  coffee  or  tea,  and  as 
a  resort  to  such  beverages  will  therefore  oidy  throw  out  of 
balance  the  regular  operation  of  these  functions,  the  physician  can 
certainly  not  advise  those  not  accustomed  to  the  use  of  such  stim- 
ulants to  become  habituated  to  them,  but,  on  the  contrary,  he 
must  dissuade  them  from  acquiring  such  a  habit.  It  is  a  differ- 
ent matter  when  one  is  already  habituated  to  the  use  of  tea  or 
coffee.  If  these  have  been  used  for  a  long  time  m  moderate 
quantities  without  exerting  any  particularly  noticeable  unfavor- 
able mfluence,  then  there  is  no  reason  for  msisting  on  absti- 
nence from  them,  because  their  discontinuance  (not  to  mention 
the  fact  that  m  the  majority  of  cases  the  physician's  prohibition 
will  be  like  unto  the  voice  clamoring  in  the  wilderness)  is  often 
accompanied  by  important  and,  in  the  case  of  an  active  life  of 
the  habitue,  very  distressing  disturbances  to  his  health.  To  be 
sure,  cases  of  abuse  of  these  beverages  with  evident  bad  conse- 
quences therefrom,  require  either  limitation  in  their  use  or  even 
total  abstinence  ;  the  latter,  as  is  evident  from  what  was  just  said 


—  75  — 

concerning  their  moderate  use,  is  to  be  accomplished  very  care- 
fully. The  use  of  wine,  brandy,  and  to  a  certain  extent  of  tobacco 
must  certainly  be  regarded  much  more  seriously,  and  their  limited 
use  or  their  discontmuance  must  be  urged  more  msistently ;  but 
I  must  say  agam,  their  total  discontinuance  is  in  certain  cases  to 
be  undertaken  with  great  caution,  after  weighing  all  the  cir- 
cumstances pro  and  contra. 

To  cause  our  patient  to  discontinue  the  use  of  tea  and  to  com- 
pel him,  in  his  present  condition,  to  give  up  an  accustomed  and 
a  most  permissible  stimulating  beverage,  would  be  not  only  m- 
expedient,  but  positively  erroneous.  Our  patient  needs  the  tea 
not  only  as  a  drink  suitable  for  diarrhoea,  but  also  as  a  gentle 
stimulant.  The  indications  for  stimulants  are  so  strong  in  this 
case  that  we  have  even  prescribed  wme  for  him,  the  indications 
for  which  have  been  pointed  out  above. 

"  We  will  now  take  up  the  question  oifood.  The  patient  was 
admitted  with  a  chronic  gastric  catarrh,  and  in  a  state  of  exacer- 
bation at  that.  We  first  of  all  took  care  to  see  to  it,  that  the 
food  did  not  irritate  the  stomach,  and  with  this  m  view  we 
ordered  it  preferably  in  a  liquid  form  (particularly  on  account  of 
the  possible,  although  hardly  probable  presence  of  ulcer  of  the 
stomach),  viz.,  such  as  would  not  irritate  mechanically ;  and  warm, 
so  as  not  to  produce  any  thermic  irritation  —  neither  hot  nor 
cold  (especially  in  view  of  the  diarrhea)  ;  and  finally  such  as 
not  to  irritate  the  stomach  chemically  (the  patient,  of  course, 
gets  no  vinegar,  mustard,  or  pepper,  etc.). 

Now  come  the  most  important  questions  concerning  the 
quantity  and  quality  of  food  and  the  time  for  taking  it. 
You  know  that  we  mstructed  our  patient  to  eat  little  at  a  time 
and  often ;  you  also  know  the  nature  of  the  food.  The  general 
success  of  the  treatment  stands  witness  to  the  fact  that  it  also 
has  been  administered  correctly.  You  are,  doubtless,  desirous  of 
knowing  why  such  an  apportionment  of  food  was  successful  and 
what  guided  us  m  prescribing  it.     We  will  take  it  up  in  order. 

The  quantity  and  the  apportionment  of  the  food.  —  If  a  patient 
with  a  catarrhal  condition  of  his  stomach  is  given,  at  his  usual 
meal-times,  for  breakfast  or  dmner,  one-haK  or  even  one-third 
of  his  ordinary  quantity  of  food,  he  will,  on  taking  it,  fail  to  ob- 


—  re- 
serve any  dyspeptic  symptoms  at  all  or  lie  will  have  them  in  a 
much  lesser  degree ;  but  he  would  usually  complain  of  either 
being  hungry  or  at  least  of  not  experencing  a  feeling  of  satiety, 
that  is,  a  sufficient  filling  of  the  stomach.  This  fact  is  the  basis 
of  the  commonly  accepted  and  very  useful  method  of  adminis- 
tering food  to  such  sick  —  little  at  a  time  and  at  frequent 
intervals.     How  is  this  to  be  ordered? 

A  sensible,  careful  patient,  with  a  strong  will-power,  is  ad- 
vised thus :  Eat  little  at  a  time,  —  enough  to  still  the  hunger, 
but  never  gorge  yourself,  not  even  to  complete  satiety ;  but  as 
soon  as  you  feel  not  merely  hungry,  but  a  lively  appetite,  eat 
again  the  same  quantity,  that  is,  without  complete  satiation. 
It  is  usually  necessary  to  add :  eat  as  slowly  as  possible ;  do 
not  hurry  (a  besetting  sin)  ;  you  will  thus  be  able  to  better 
chew  the  food  and  will  observe  that  your  hunger  is  the  sooner 
satisfied :  you  finish  eating  before  being  over-sated.  To  be  sure, 
even  with  such  patients  and  with  such  instructions  we  do  not  al- 
ways at  once  get  good  results  ;  but  we  at  once  establish  the  proper 
quantity  of  food  to  be  taken  at  one  time.  Patients  are  liable 
to  either  overeat,  or  to  eat  too  little  at  a  time,  if  frightened  by 
too  energetic  instructions  from  the  physician,  particularly  if 
they  be  over-scrupulous  :  they  will  not  repeat  the  meal  often 
enough,  and  by  going  hungry  interfere  with  the  success  of  the 
treatment.  But  if  the  physician  follows  attentively  the  course 
of  treatment  and  repeatedly  offers  additional  explanations,  then 
the  patient  will  acquire  the  habit  of  taking  his  meals  regularly, 
thus  guaranteeing  a  healthy  condition  of  the  stomach  also  for 
the  future. 

On  the  other  hand,  in  some  cases  —  as,  for  instance,  m  our  pa- 
tient —  such  instructions  are  not  sufficient.  He  was  habituated 
to  poorly  nutritious,  bulky  and  difficultly  digestible  food ;  here 
he  gets  food  that  is  nourishing,  of  small  bulk,  easily  digested, 
and  besides  more  palatable  and  more  appetizing.  It  is,  there- 
fore, rather  dilhcult  for  him  to  observe  the  principal  require- 
ment in  eating,  namely  to  eat  till  hunger  is  satisfied,  and  not  to 
satiety.  If  the  quantity  of  food  be  not  clearly  limited,  he  will 
always  overeat.  In  such  cases  the  physician  must  do  as  we 
have  done  :  havmg  explained  to  the  patient  the  above-mentioned 


—  77  — 

requirement,  define  exactly  the  quantity  of  food  and  the  fre- 
quency of  the  meals,  and  then  verify  their  correctness  by 
observation,  increasing  or  diminishing  the  quantity  of  and  the 
intervals  between  the  meals  in  accordance  with  the  degree  of 
the  dyspeptic  phenomena  and  the  condition  of  the  appetite. 
The  gradual  increase  in  the  general  quantity  of  food  runs  par- 
allel to  the  improvement  m  the  condition  of  the  stomach,  as 
you  see  clearly  from  the  j)resent  case. 

It  is  even  more  difficult  to  properly  prescribe  the  quality  of 
the  food.  To  be  guided  only  by  general  hygienic  and  phj'sio- 
logical  data  will  not  bring  the  desired  results,  as  even  little 
experience  will  prove :  isolated  cases  are  too  often  met  with 
presenting  too  great  idiosjmcrasies.  In  consideration  of  this  it 
only  remams  to  thoroughly  study  the  given  case.  Our  patient 
had  a  gastric  catarrh  while  mgesting  poorly  nourishing  food, 
that  was  Imlky  and  not  frequently  taken ;  we  proved  success- 
ful with  him  while  givmg  him  food  of  an  exactly  opposite 
nature.  In  other  cases,  as  for  instance,  in  those  of  pure  ner- 
vous dyspejDsia,  uncomplicated  by  catarrh,  nourishmg  but  too 
delicate  food  is  often  successfully  replaced  by  a  coarser  food. 
To  be  sure,  we  may  run  across  some  verj-  difficult  cases ;  but  a 
careful  investigation  of  every  given  case,  of  the  habits  and 
peculiarities  of  the  patient  as  regards  his  food  (as  to  which  kind 
of  food  agrees  with  him  and  which  not)  will  always  enable  us 
to  prescribe,  in  accord  with  the  hygienic  and  physiological  data, 
the  first,  so  to  speak,  trial  food,  and  later,  guided  by  the  results 
obtamed,  to  gradually  formulate  a  correct  selection,  thus  at  the 
same  time  teachmg  the  patient  how  to  preserve  the  stomach  m  a 
healthy  condition.  I  must  here  enter  my  protest  against  the 
use  of  the  stomach  sound  for  verifymg  the  correctness  of  the 
prescribed  food  still  more  forcibly  than  I  did  while  we  discussed 
its  use  for  diagnostic  purposes  hi  gastric  diseases :  iu'st,  because 
the  results  of  verification  obtained  by  the  sound,  with  the 
methods  at  present  m  use,  are  less  reliable  than  those  obtained 
by  ordinary  observation ;  and  then,  the  introduction  of  the 
somid,  especially  if  frequent,  may  undoubtedly  hinder  digestion 
and  become  prejudicial  to  the  favorable  course  of  the  disease. 

The  food  must  be  varied  within  limits  admissible  for  the  pa- 


—  78  — 

tient,  but  it  must  be  prepared  plainly,  without  suspicious  sauces 
and  dressings,  but  palatable  withal. 

In  prescribing  a  diet  for  our  patient,  it  was  not  only  the  con- 
dition of  the  stomach  that  was  taken  into  consideration.  The 
intestinal  catarrh,  as  apparent  from  the  diarrhoea,  required  cer- 
tain peculiarities  in  the  prescription,  as  has  been  noted  above ; 
the  prescription  would  be  different  in  the  case  of  constipation, 
which  is  seen  oftener  than  diarrhcjea  in  gastric  catarrh.  The 
disturbances  m  the  patient's  nutrition  also  require  a  different 
diet.  We  have  been  able  to  a  certain  extent  to  conform  our 
treatment  to  these,  especially  as  regards  the  oxaluria,  having 
prescribed  for  him  preferably  a  nitrogenized  food  with  a  prohi- 
bition of  sweets  (excepting  a  very  trifling  quantity  of  sugar 
with  his  tea)  ;  this,  as  has  been  proved,  was  not  only  permis- 
sible, but  even  requisite  in  the  condition  of  his  stomach  and 
intestines.  The  present  condition  of  his  digestive  organs  cer- 
tamly  does  not  permit  the  use  of  a  fattening  diet,  which  is 
indicated  by  his  extreme  leanness,  as  for  mstance,  cod-liver  oil 
or  large  quantities  of  milk  or  its  preparations.  Time  will  show 
how  far  such  a  diet  may  be  necessary  and  when  its  use  is  pos- 
sible. It  will  also  be  our  task  to  gradually  change  his  present 
food,  in  accordance  with  the  rapidity  of  his  convalescence,  to 
his  habitual  coarser  diet,  which  he  will  return  to  after  leavmg 
our  clinic. 

Taking  up  the  treatment  proper,  we  will  follow  the  same  or- 
der as  laid  down  m  our  Introduction  to  Clinical  Work,  and  which 
has  been  followed  in  our  investigation  and  diagnosis. 

The  stomach.  —  The  indication  for  Ems  water  will  be  spoken 
of  separately,  for  reasons  we  have  already  explamed.  Why  did 
we  prescribe  for  our  patient  decoction  of  condurango  and  tincture 
of  nux- vomica  ?  The  so-called  hitters  are  useful  m  chronic  catarrh 
of  the  stomach.  Without  discussing  the  pharmacological  reason 
for  their  action,  I  will  say  that  clinically  their  use  is  of  un- 
doubted utility :  when  taken  at  meal-times  they  alleviate  the 
dyspeptic  symptoms.  Condurango,  notwithstanding  its  slightly 
bitter  taste,  acts  like  the  bitters  (by  diminishing  the  dyspeptic 
phenomena)  even  better  than  those  formerly  used.  Besides, 
condurango  is  very  useful  in  diarrhoea,  which  will  sometimes 


—  79  — 

pass  off  by  the  use  of  this  drug  alone.  The  nux-vomica 
drops  are  added,  —  first,  because  they  are  strongly  bitter  (the 
slightly  bitter,  insipid  taste  of  condurango  is  even  somewhat 
unpleasant  to  patients,  who  usually  prefer  the  addition  of  nux- 
vomica),  and  secondly,  this  drug,  because  of  the  strychnine,  will 
act  as  a  tonic  to  the  weakened  nervo-muscular  apparatus  of  the 
intestines,  and  our  patient,  as  you  will  recollect,  suffered  from 
almost  constant  constipation  until  last  August.  It  is  also  con- 
venient to  admmister  condurango  and  nux-vomica  in  the  follow- 
ing formula :  ]^  —  Extracti  fluidi  condurango  3  j,  tmcturse 
nucis-vomicse  3  ij.  M.  D.  S.  20  -  25  drops  in  one-half  wuie- 
giass  of  warm  water  twice  a  day  after  meals. 

Intestines.  —  The  measures  to  combat  the  diarrhoea,  the  intes- 
tinal catarrh,  are  as  follows  :  rest  m  recumbent  position,  warmth 
(warm  food,  a  warm  abdominal  supporter,  warm  baths),  improv- 
ment  m  the  condition  of  the  stomach,  of  the  gastric  digestion, 
and,  as  mentioned  above,  condurango.  We  have  already 
explained  why  we  prescribed  codeine  and  the  tincture  of  opium, 
(for  pain),  why  we  give  coto  drops  and  not  tannin  or  other 
astringents,  —  and  why  we  did  not  resort  to  tannm  or  any  other 
clysters. 

The  gall-bladder.  —  Ems  water  was  prescribed  agamst  biliary 
calculi,  because  clmical  and  partly  pharmacological  data  lead  to 
the  conclusion  that  the  alkalme  mmeral  waters,  to  which  class, 
as  you  know,  the  Ems  water  belongs,  have  the  tendency  to  re- 
duce the  size  of  and  break  up  the  calculi,  thus  facilitating  their 
expulsion.  This  will  also  be  expedited  in  our  patient  by  the 
improvement  in  the  gastro-intestinal  digestion  and  in  the  nutri- 
tion. The  correction  of  faults  in  diet,  rest,  the  avoidance  of 
traumatic  mfluences,  warmth  (warm  abdominal  bandages  and 
warm  baths),  and  the  strengthening  of  the  nervous  system 
brought  about  by  the  relief  of  the  various  pains  and  the  im- 
provement in  sleep  —  all  these  will  tend  to  dimmish  the  con- 
stant tenderness  of  the  gall-bladder  and  to  avert  attacks  of 
biliary  colic. 

The  Kidneys.  —  For  the  oxalic  acid  gravel  we  prescribed  the  ■ 
Ems  water,  although  alkaline  mineral  waters  are  properl}^  more 
suitable  for  renal  gravel  of  another  nature  —  namely,  the  uric 


acid  gravel,  which  is  usually  found  not  with  pale  urine,  as  that  of 
our  patient  and  of  oxaluria  in  general,  but  in  urine  that  is  more 
strongly  colored  than  normal,  namel}^,  orange-yellow  or  even 
orange-red.  Against  oxalic-acid  gravel  are  particularly  indica- 
ted the  earthy  (containmg  lime)  mineral  waters,  as,  for  instance, 
Contrexeville ;  but  we  could  not  prescribe  these  waters,  as  they 
would  act,  especially  in  our  patient,  as  laxatives,  thus  prolong- 
ing the  exhaustmg  diarrhoea.  It  is  the  meat  diet,  the  improve- 
ment in  nutrition  and  in  digestion,  general  massage,  and  the 
improvement  in  the  condition  of  the  nervous  system,  that  will 
diminish  the  production  of  the  oxalic-acid  gravel  and  stop  the 
oxaluiia.  The  diminution  in  the  tenderness  of  the  kidneys,  and 
the  cessation  of  attacks  of  renal  colic,  will  be  effected  by  the  same 
measures,  as  were  recommended  for  the  gall-bladder  symptoms, 
namely,  rest,  warmth  and  a  strengthened  nervous  system.  As 
it  is  quite  probable  that  the  patient's  left  kidney  is  somewhat 
movable,  it  will  become  necessary  for  him,  later  on,  when  he 
moves  about  more  freely,  to  wear  a  special  kidney  bandage,  in 
place  of  the  msufficient  simple  abdominal  band. 

The  heart.  —  The  weak  cardiac  activity  required  stimulation ; 
we  have  spoken  above  of  the  mdication  for  wme  m  connection 
with  this. 

Nutrition.  —  We  just  now  mentioned  the  measures  for  com- 
batmg  the  oxaluria.  While  discussmg  the  diet  we  spoke  of 
what  could  be  done  for  the  patient  in  his  present  condition  for 
the  extreme  emaciation. 

The  nervous  system  in  general,  the  musculo^nervous  apparatus, 
the  constitution  of  the  patient.  —  We  first  of  all  attempted  to  im- 
prove the  patient's  sleep,  for  as  long  as  there  is  sleeplessness 
we  cannot  expect  any  improvement  either  in  the  nervous  sys- 
tem or  in  the  condition  of  the  whole  organism.  We  succeeded 
in  gaining  a  considerable  improvement  m  this  direction  by  re- 
lieving the  various  pams  and  by  the  use  of  warm  baths  and  of 
general  massage ;  all  this  has  already  been  spoken  of.  Besides, 
the  special  object  m  the  use  of  massage  lies  m  the  improvement 
of  nutrition  and  in  the  development  of  the  nervo-muscular  ap- 
paratus, in  the  mcrease  of  muscular  strength,  which,  after  the 
local  ailments  shall  have  been  removed  and  improvement  in  the 


—  81  — 

general  nutrition  having  been  attained,  will  become  the  startmg- 
point  for  the  possible  improvement  in  the  constitution  of  the 
patient. 

It  now  remains  for  us  to  explain  why  we  prescribed  Ems 
water  for  our  patient,  and  coincidently  we  shall  speak  of  mmeral 
waters  in  general. 


LECTURE  OF  OCTOBER  6,  1889. 

The  patient's  condition  is  improving  constantly;  the  pre- 
scribed treatment  is  justified  by  the  obtamed  results  and  requires 
almost  no  alterations ;  there  is  therefore  no  necessity  for  bring- 
ing the  patient  before  you  as  frequently  as  before.  The  patient 
was  given,  as  you  remember,  at  the  begmnmg,  daily,  two  glasses 
of  milk,  two  glasses  of  soup  with  broken-up  meat,  two  eggs,  less 
than  one-fourth  pound  of  white  bread  and  three  spoonfuls  of 
wine.  He  still  gets  two  glasses  of  milk  with  cognac,  two  glasses  of 
soup  with  meat,  two  eggs,  more  than  one-half  pound  of  white 
bread,  two  glasses  of  milk  soup  with  manna,  one-fourth  of 
a  chicken,  two  meat  cutlets,  and  the  wine  as  before ;  but  the  ap- 
petite is  constantly  mcreasing  and  the  patient  begs  for  more 
food.  This  quantity  of  food  is  well  digested,  without  anj-  dys- 
peptic phenomena,  unless  it  be  some  belching  at  times,  which  is 
easy,  pamless,  odorless  and  non-acid.  Very  rarely,  when  the 
patient  feels  strong  hunger,  there  appears  a  slight  pain  m  the 
region  of  the  stomach,  but  this  ceases  at  once  on  taking  some 
food.  This  pain  is  but  an  indication  of  a  greater  necessitj'  for 
nourishment,  a  necessity  that  appeared  simultaneously  with  the 
improvement  in  the  condition  of  the  stomach.  Considering  the 
patient's  extreme  emaciation  and  the  fact  that  he  is  as  yet  grow- 
mg  (he  is  but  eighteen  years  old),  this  necessity  is  certainly  not 
to  be  wondered  at.  The  evacuations,  once  a  day,  are  normal, 
more  frequentl}^  of  a  solid  consistence  (we  have  given  no 
oj)ium  since  September  27th).  The  abdomen  is  not  distended, 
notwithstanding  the  abmidant  quantity  of  food  and  the  not  very 
copious  excretions,  which  fact  points  to  a  normal  intestmal  ab- 
sorption ;  this  is  also  apparent  from  the  cessation  of  the  for- 
merly frequent  rumblmg.      The  spontaneous  abdommal  pams  are 


—  82  — 

.  insignificant,  appeariag  only  on  walking  —  in  the  region  of  the 
left  kiclnej.  Examination  of  the  abdomen  elicits  a  marked  tender- 
ness in  the  same  region,  and  a  trifling  sensitiveness  ui  the  region 
of  the  sigmoid  flexure  and  in  that  of  the  gall-bladder.  The  urine 
is  not  pale,  but  of  normal  color,  does  not  become  turbid  so  readily 
as  it  did  formerly :  the  oxalate  of  lime  sediment  is  contmually 
decreasing,  while  that  of  sodium  urate  has  increased  a  little,  but 
ceased  to  increase  further.  The  pulse  is  contmuously  improv- 
ing. Patient's  appearance  is  better  than  before ;  he  has  gained 
three  pounds  smce  admission  (he  weighs  ninety-four  pounds). 
The  pit}'Tiasis  versicolor  is  passing  away  —  is  less  scaly  and 
paler.  The  sleep  is  better ;  the  mmd  is  clear,  the  strength 
mcreases  little  by  little :  the  patient  is  able  to  stand  up  longer 
(this  used  to  produce  dizziness)  and  to  walk  more. 

How  shall  we  continue  the  treatment  ?  We  will  add  another 
half  glass  of  Ems  water  (so  that  the  patient  will  be  taking 
half  a  glass  three  times  a  day,  each  time  about  one  hour  be- 
fore a  meal)  with  a  view  to  more  effectively  diminish  the  kidney 
pains,  which  may  be  due  to  the  oxalic-acid  gravel.  To  use  the 
Contrexeville  water  for  this  would  be  rather  risky,  because,  as 
we  explained  before,  it  might  cause  a  return  of  the  diarrhoea. 
Even  a  somewhat  larger  dose  of  Ems  water,  though  it  be  luke- 
warm, would  tend  to  prolong  an  existing  diarrhoea.  We  have 
therefore  limited  the  dose  until  now  to  two  half-glassfuls  of  this 
water ;  but  now,  with  the  improved  condition  of  the  intestines, 
we  can  give  some  more  of  the  Ems  for  the  above-mentioned 
purpose.  The  condurango  and  the  nux  vomica  will  be  contin- 
ued for  a  long  time ;  experience  has  proven  the  utility  of  such 
a  procedure  in  cases  similar  to  ours,  in  a  gastric  catarrh  of  such 
duration  and  with  a  simultaneous  mtestinal  catarrh.  Guided  by 
experience,  we  will  continue  the  coto  drops  some  time  even  after 
the  cessation  of  the  diarrhoea,  and  then  leave  them  off  gradually. 
As  is  apparent  from  what  was  said,  we  must  continue  the  wine, 
massage,  and  at  times  the  baths. 

May  we  recommend  for  our  patient  walkuig  out-of-doors  ?  He 
has  grown  somewhat  stronger,  the  weather  is  pleasant,  and  the 
fresh  ail'  would  certainly  be  very  beneficial  for  him.  But  it  is  bet- 
ter to  abstam,  as  yet,  from  recommendmg  such  walks.    Although 


—  83  — 

surely  better  than  before,  the  patient's  strength  is  still  not  very 
great ;  besides,  he  still  takes  at  times  the  warm  baths  so  necessary 
for  him.  There  is  therefore  a  risk  of  jeopardizmg  the  patient's 
condition  through  fatigue  from  walking  and  a  possible  cold  ;  this 
might  bring  on  a  return  of  the  diarrhcea,  or  it  might  increase  the 
renal  pains.  Besides,  the  walks  are  not  necessary  for  him  as  yet : 
the  patient's  appetite  is  excellent  and  his  sleep  satisfactory. 


Before  passing  on  to  the  mineral  waters,  I  consider  it  neces- 
sary to  say  a  few  words  about  those  methods  of  treatmg  gastric  dis- 
ease to  which  I  have  not  resorted  in  the  present  case.  A  review,  if 
not  of  all,  then  at  least  of  the  most  generally  used  methods  of 
treatment  of  gastric  diseases  in  connection  with  our  first  case, 
will  be  advantageous  in  explaining  the  relative  usefulness  of  the 
various  methods  of  this  therapy,  and  will  make  still  clearer  the 
reason  why  we  have  treated  our  patient  as  we  did  and  not 
otherwise. 

'Hydrochloric  acid  was  proposed  for  facilitatmg  gastric  diges- 
tion some  thirty  years  ago  ;  and  smce  it  has  been  shown 
experimentally  that  the  secretion  of  this  acid  by  the  stomach 
diminishes  at  times,  or  is  even  entirely  suspended,  its  therapeu- 
tic application  seemed  to  become  even  more  judicious.  During 
the  first  year  of  my  clinical  practice  (also  some  thirty  years 
ago)  I  made  use  of  this  acid ;  but  the  results  obtained  compelled 
me  to  dismiss  it,  so  that  since  then  I  do  not  resort  to  it  (I 
shall  mention  later  the  only  exception  where  I  use  it  still).  At 
consultations,  however,  I  have  had,  and  have  now,  opportunities 
to  see  it  employed  in  diseases  of  the  stomacli.  As  before,  so  at 
the  present  time,  with  the  condition  of  the  stomach  so  carefully 
investigated  by  the  modern  methods,  the  results  of  its  use  are 
identical.  First,  they  are  very  inconstant,  the  acid  benefiting 
the  patient  at  times,  but  oftener  not,  on  the  contrary  impairing 
the  appetite,  causing  pains  in  the  region  of  the  stomach,  —  in 
short,  tending  to  hmder  digestion ;  second,  even  when  it  does  bene- 
fit the  patient,  the  relief  is  only  temporary,  i.  e.,  it  assists  in  promot- 
ing the  digestion  of  the  meal  with  which  it  was  taken,  but  does  not 
cure  the  disease  that  causes  the  dj'spepsia.     If  this  latter  disease 


—  84  — 

be  a  catarrh  of  the  stomach,  then  it  will  be  necessary  to  cure  it 
with  alkalines,  bitters,  lavage ;  if  the  dyspepsia  be  of  nervous 
origin,  then  we  must  resort  to  a  radical  treatment  of  the  gen- 
eral nervous  disturbance.  At  the  same  time,  hydrochloric  acid, 
being  but  a  palliative  remedy,  while  helping  (which  it  rarely 
does),  will  disguise  the  results  of  the  radical  treatment,  and  will 
prevent  the  formation  of  a  correct  idea  as  to  the  success  of  the 
latter ;  while  in  case  it  does  not  relieve,  it  may  become  harmful, 
causing,  as  we  said  above,  a  disturbance  of  digestion  and  even 
of  nutrition,  if  used  for  a  long  time. 

We  alluded  above  to  the  employment  of  hydrochloric  acid  in 
diseases,  in  which  the  secretion  of  this  fluid  by  the  stomach,  or 
rather,  in  which  the  action  of  the  acid  secreted  by  the  stomach  on 
food,  is  made  difhcult,  in  catarrhal  conditions  by  the  presence  of 
mucus,  in  gastric  dilatation  by  the  accumulated  contents.  (Dr. 
Popoff,  whose  work  I  have  already  mentioned,  found  the  secre- 
tion proper  of  hydrochloric  acid  by  the  stomach  in  these  diseases 
to  be  normal  in  a  very  great  number  of  both  experimental  and 
clmical  cases  investigated  by  him.)  While  in  cases  where  the 
secretion  of  this  acid  is  entirely  absent  and  cannot  be  made  to 
reappear,  that  is,  in  atrophy  of  the  stomach,  when  its  glands  are 
destroyed,  the  palliative  results  obtamed  through  the  employ- 
ment of  the  acid  are  trifling  and  not  to  be  relied  on  as  tending  to 
prolong  to  any  extent  the  life  of  the  patient.  At  all  events,  as 
you  may  know,  hydrochloric  acid  is  neither  employed  nor  valued 
in  diseases  of  the  stomach  as  much  at  present  as  it  was  formerly. 

Of  the  employment  of  pepsm  and  trypsin,  in  the  form  of  an  ex- 
tract of  the  pancreas,  I  must  say  the  same  that  I  said  of  the 
employment  of  hydrochloric  acid,  and  again  with  the  same 
exception. 

Such  a  conclusion  concerning  these  three  remedial  agents  re- 
fers to  the  condition  of  things  at  present  only,  without,  of  course, 
making  any  predictions  in  regard  to  their  future  application. 

The  exception,  which  was  spoken  of  before,  refers  to  cases  of 
gastric  dyspepsia  in  chlorosis  and  other  anaemic  conditions,  m 
which  the  secretion  of  the  gastric  juice  is  very  much  decreased, 
and  where  hydrochloric  acid  administered  after  meals  sometimes 
gives  good  results.     The  complete  cessation  of  dyspeptic  phe- 


—  85  — 

nomena  even  in  these  cases  can  only  be  obtained  however  by  a 
radical  cure  of  the  above-named  diseases. 

Here  I  must  also  mention  the  various  food-compounds,  pre- 
pared so  as  to  make  them  very  suitable  for  digestion,  as  meat- 
juice,  (beef-juice),  meat  powder,  peptonized  albuminates  and  the 
like.  I  personally  do  not  employ  them,  but  as  a  consultant  have 
seen  them  used  in  quite  a  number  of  cases.  I  could  never  per- 
suade myself  as  to  the  necessity  for  their  employment.  In  the 
majority  of  cases  their  use  is  not  followed  by  any  particular 
results ;  while  in  those  rare  cases  where  the  patients  bore  them 
well  —  when  unable  to  bear  ordinary  food  —  and  even  improved 
on  their  use,  investigation  has  shown  that  either  the  "  orclmary  " 
food  was  unsuitable,  or  that  the  treatment  followed  at  the  time 
of  its  administration  was  wrong,  and  the  food  could  not  there- 
fore be  borne.  I  will  also  add  that,  through  the  careless  prepa- 
ration and  preservation  of  these  so-called  "  especially  digestible  " 
foods,  which  are  unfortunately  much  more  frequent  than  their 
conscientious  manufacture,  they,  bemg  generally  unpalatable,  be- 
come repugnant  to,  and  may  even  harm,  the  patient,  probably  on 
account  of  the  ptomaines  developed  in  them.  The  relatively 
high  price  of  these  food  preparations  must  also  be  taken  into 
account. 

We  employed  no  lavage  of  the  stomach  m  the  present  case, 
as  there  was  no  uidication  for  it,  viz.,  distention  of  the  stomach 
by  the  accumulated  contents  (as  we  pomted  out  m  our  diagnosis), 
—  not  to  speak  of  the  exacerbation  of  the  catarrhal  condition, 
just  before  he  was  admitted  (pains  m  the  stomach  and  daily  vom- 
iting), which  was  a  strong  coutra-indication  for  gastric  lavage. 
The  success  of  our  treatment  is  a  sufficient  proof  that  there  was 
in  reality  no  necessity  for  the  employment  of  this  method  of 
treatment.  I  hope  to  present  to  you  at  my  next  lecture  a  case 
with  indications  for  gastric  lavage,  and  I  will  then  discuss 
thoroughly  the  necessity  for  its  employment  in  its  correct  appli- 
cation, in  which  it  is  a  most  useful  method  of  treatment. 


86  — 


LECTURES   OF  OCTOBER   10  AND   II,   1889. 

It  remains  to  be  explained  why  we  prescribed  for  our  patient 
a  mineral  water ;  why  particularly  the  Ems ;  why  in  the 
quantity  designated ;  and  why  at  certain  times  (one  hour  before 
the  meal),  etc. 

Of  all  known  remedies  for  catarrh  of  the  stomach,  and  also 
of  the  upper  portion  of  the  mtestines,  of  the  biliary,  urinary  and 
respiratory  tracts,  for  biliary  calculi,  renal  gravel  and  gout,  sodi- 
um in  the  form  of  the  bicarbonate  and  the  chloride  is  considered 
the  best.  What  is  the  most  convenient  form  for  administering 
these  combinations  of  sodium  in  gastric  catarrh  ?  At  the  begin- 
ning of  my  medical  practice  I  occasionally  saw  sodium  bicarbon- 
ate admmistered  even  in  pills, — the  least  suitable  form:  for 
along  with  the  medicament  itself,  the  bicarbonate,  there  was  in- 
troduced into  the  stomach  m  large  quantities  a  pillular  mass 
(extr.  taraxaci,  etc.)  that  uselessly  burdened  the  organ  and 
only  served  as  an  obstacle  to  the  efficiency  of  the  sodium.  The 
best  form  is  without  doubt  a  solution,  m  which  the  above  named 
compounds  of  sodium  come  in  contact  with  the  mucous  membrane 
of  the  stomach  in  the  easiest  and  most  equable  manner. 

Sodium  bicarbonate  and  sodium  chloride  are  often  given,  with 
the  addition  of  laxative  salts,  if  necessary,  in  powders,  the  pa- 
tient being  directed  to  dissolve  them  in  a  certam  quantity  of 
water.  The  chief  recommendation  for  such  a  form  is  its  cheap- 
ness ;  but  it  has,  unfortunately,  numerous  drawbacks  :  the  patient 
may  not  always  take  of  the  supply  prepared  by  the  druggist  a 
uniform  quantity,  nor  does  he  always  dissolve  it  m  a  like  quan- 
tity of  water  (the  degree  of  concentration  of  the  solution  is  quite 
important) ;  and,  what  is  most  important,  he  dissolves  the 
powders  m  w^ater  of  an  uncertam  composition.  This  water  may 
contam  substances  either  directly  harmful  to  the  stomach  (usu- 
ally an  abmidance  of  lime  compounds),  or  such  as  will  change 
the  composition  and  through  this  the  effectiveness  of  the 
powder  dissolved  in  it.  To  have  powders  prepared  in  a  drug- 
store, weighed  out  for  each  dose  (often  several  times  daily), 
would   destroy   the  princi]3al   advantage  of  this  method  —  its 


cheapness  —  considering  the  value  of  the  apothecary's  labor ; 
while  to  have  an  exactly  prepared  solution  made  with  carefully 
selected  soft  water  (containing  but  few  hard  particles ;  not  to 
speak  of  distilled  water)  for  daily  use,  would  make  such  treat- 
ment very  expensive.  It  thus  remains  to  prepare  exact  solutions 
iu  great  quantities  in  factories,  which  is  certainly  much  cheaper, 
and  which  we  see  in  establishments  for  artificial  mineral  waters. 

Can  artificial  mineral  waters  replace  the  natural  ones  ?  My 
long  experience  teaches  me  to  prefer  the  natural  ones,  used 
either  at  the  places  they  are  formd,  or  in  the  patient's  house 
when  imported.  We  certainly  can  not  deny  the  efficiency  of 
the  artificial  waters,  which  may,  m  the  absence  of  the  natural 
ones,  suffice,  if  they  are  carefully  prepared.  Unfortunately  this 
latter  circumstance  is  rather  a  rarity.  The  difference  in  the 
prices  of  the  natural  and  artificial  waters  is  very  small,  owing  to 
their  mutual  competition.  Besides,  the  mineral  waters  are 
bemg  employed  now  m  much  smaller  doses  than  they  were 
formerly,  (of  this  later),  and  treatment  by  them  can  by  no 
manner  of  means  be  designated  as  more  expensive  and  less 
accessible  than  treatment  by  other  drugs,  —  rather  the  contrary. 
As  regards  the  efficiency  of  the  natural  mmeral  waters  as  com- 
pared with  the  above  described  powders,  for  the  composition  of 
which  they  usuall}^  serve  as  specimens,  the  superiorit}^  of  the 
former  is  so  immense  as  not  to  admit  of  any  comparison. 
Many  a  time  have  I  seen  a  complete  cure  by  the  regular  employ- 
ment of  mmeral  waters  m  cases  of  gastric  catarrh,  constipation, 
renal  and  biliary  colic,  in  which  the  long  contmued  use  of  the 
powders  was  productive  only  of  failure. 

At  the  beginnmg  of  my  medical  practice  the  customar}^  course 
was  as  follows :  during  the  summer,  patients  were  either  sent 
directly  to  the  mmeral  springs,  or,  if  not  sent  there,  they  were 
ordered  to  take  artificial  waters  and  at  times  natural  imported 
ones.  At  the  other  seasons  of  the  year  the  above-named  powders 
and  pills  were  prescribed.  The  difference  m  the  results  of  the 
treatment,  made  more  prominent  by  the  dissimilar  conditions  of 
life  during  the  warm  and  cold  seasons  of  the  year,  at  the  place 
of  the  patient's  regular  residence,  or,  in  case  of  his  having  gone 
to  the  waters,  amid  completely  changed  surroundings,  was  very 


striking  indeed.  I  therefore,  from  the  very  beginning  of  my 
clinical  and  independent  medical  practice  began  to  use  the 
mineral  waters,  mostly  natural  ones,  all  the  year  round,  exercis- 
ing due  caution,  of  course;  —  the  routme  habit  was  so  strong,  and 
the  possible  dangers  from  the  use  of  mineral  waters,  especially 
warm  ones,  m  the  cold  season,  were  so  great.  Physicians  who 
quietly  looked  on  while  their  patients  imbibed,  both  in  winter 
and  summer,  some  five  to  ten  cups  and  more  of  hot  tea  daily, 
felt  anxious  lest  these  patients  should  catch  cold  by  di-mking 
three  times  a  day  half  a  glass  of  Ems  or  Karlsbad  water,  which, 
although  somewhat  warmed,  was  still  of  a  lower  temperature 
than  the  customary  beverages.  But  the  force  of  circumstances, 
aided  by  my  practice  and  that  of  my  assistants  and  former 
students  at  the  clinic,  has  triumphed  at  last,  so  that  now  in 
Moscow,  as  well  as  in  Russia  generally,  the  use  of  mineral 
waters  at  every  season  of  the  year  has  replaced  the  pills  and  to 
some  extent  the  powders  ;  although  even  at  the  present  time  in 
some  university  cities  with  clinics,  and  partly  within  the  circles 
of  their  medical  mfluence,  the  improved  practice  is  either  alto- 
gether absent  or  is  only  slowly  being  mtroduced. 

Appreciatmg  highly,  for  reasons  just  explained,  the  import- 
ance of  mmeral  waters,  I  lecture  on  them  every  year  to  my 
students. 

I  consider  it  the  business  of  the  clmic  to  impart  to  the  future 
physicians  the  skill  m  selecting  and  the  technique  of  using  the 
mineral  waters  ;  and  the  personal  experience  of  my  former  stu- 
dents, testifymg  to  the  benefit  derived  from  these  lectures, 
impels  me  to  continue  m  the  same  Ime. 

It  becomes  apparent  from  the  above  why  we  prescribed  for 
our  patient  the  best  remedies  agamst  gastric  catarrh  —  bicarbo- 
nate of  soda  and  sodium  chloride  —  in  the  form  of  a  mineral 
water.  The  question  arises  now,  why  have  we  selected  the 
Ems  water  and  no  other?  To  answer  this  and  at  the  same 
time  to  show  by  what  we  are  guided  m  selecting  a  mineral 
water,  we  will  compare  the  Ems  water  with  others  containing 
the  above-named  combinations  of  sodium.  But  I  must  before- 
hand say  a  few  words  in  explanation  of  the  difficulties  en- 
countered by  the  young  physician  in  selecting  a  mineral  water 


—  89  — 

in  any  given  case,  and  thus  explain  to  you  the  duty  of  the  in- 
structor m  impressing  upon  you  the  acquisition  of  the  ability  to 
make  this  selection.  Our  physician  opens  his  text-book  of 
pathology  and  therapeutics  and  looks  for  the  indications  for  the 
employment  of  the  mineral  waters  in  the  given  case  —  say 
catarrh  of  the  stomach :  the  text-book  recommends  Ems,  Vichy, 
Yessentucki,  Karlsbad,  etc.  ;  for  biliary  calculi,  Karlsbad,  Vichy, 
Yessentucki,  etc ;  for  renal  gravel,  Vichy,  Yessentucki,  Karls- 
bad, etc  ;  but  which  water  is  he  to  order?  No  answer.  He 
then  looks  in  his  text-book  of  balneotherapy  for  advice,  and 
finds  that  Ems  is  recommended  for  gastric  catarrh,  biliary  calculi 
and  renal  gravel ;  Vichy  and  Yessentucki  for  gastric  catarrh, 
biliary  calculi  and  renal  gravel ;  and  Karlsbad  for  gastric  catarrh, 
biliary  calculi  and  renal  gravel.  The  text-books  evidently  do 
not  help  one.  It  is  only  m  the  clinic,  that  is,  m  presence  of  the 
given  cases,  that  we  can  show  in  a  correct  way,  in  the  very  best- 
manner,  how  the  choice  of  a  mmeral  water  is  to  be  made.  The 
clinic  certainly  does  not  exclude  the  text-books  on  balneotherapy, 
nor,  those  on  special  pathology  and  therapeutics,  —  they  are 
surely  necessary ;  but  the  clinic  supplies  the  kej-  to  them,  and 
teaches  how  to  make  use  of  the  material  therein  contamed. 

Let  us  take  for  comparison  the  mineral  waters  of  Ems,  Ober- 
salzbrunnen,  Vichy,  Yessentucki,  Karlsbad,  Franzensbad,  Ma- 
rienbad  and  Kissingen.  We  will  also  have  to  discuss  the 
so-called  bitter  waters,  which  contain  principally  laxative  salts 
(such  as  Fiedrichshall,  Piillna,  and  our  Caucasian  spring  "  Maria 
Theresia  "  )  as  well  as  the  earthy  waters  (as  Contrexeville),  — 
since  the  first  named,  although  of  course  employed  separately, 
are  sometimes  used  in  conjunction  with  the  latter  ones ;  while 
the  indications  for  the  others  are  at  times  not  clearly  distin- 
guishable from  those  we  have  mentioned.  We  will  thus 
speak  of  the  most  important  mineral  waters  employed  for  inter- 
nal use,  except  those  containing  iron  and  arsenic,  which  we  will 
have  occasion  to  discuss  in  the  treatment  of  chlorosis  and  aneemia. 
I  have  selected  the  above  enumerated  waters  because  they  are 
the  best  known  and  the  most  studied  from  a  chemical,  clinical 
and  to  some  extent  physiological  standpoint,  and  because,  if 
correctly  employed,  they  are  undoubtedly  efficacious. 


—  90  — 

Experience  of  many  years  —  for  some  of  them,  of  centuries  — 
has  proved  that  they  contain  a  happy  combination  of  curative 
agencies,  which  are  very  beneficial  in  many  frequently  occurring 
and  important  diseases ;  besides,  they  present  tyjyes  for  compar- 
ison with  many  other  mmeral  waters,  so  that  m  discussing  these 
we  discuss  not  the  individual  waters,  but  whole  classes  of  them. 
I  have  just  said  that  the  mineral  waters  selected  by  me  for 
comparison  contam  a  happ}^  combmation  of  curative  agencies. 
"What  are  these  agencies  ?  Water,  carbonic  acid,  bicarbonate 
of  soda,  sodium  chloride,  and  laxative  salts  (sulphate  of  soda 
and  sulphate  of  magnesia).  The  constituents  of  the  mineral 
waters  enumerated  are  found  in  a  comparatively  large  quantity ; 
they  contain  besides  some  other  solid  components  m  a  small, 
even  infinitesimal  quantity,  as  compared  with  those  mentioned. 
The  importance  of  the  latter  is  not  absolutel}-  known.  In  se- 
lecting a  mineral  water  we  generally  take  into  account  the 
constituents  found  in  a  com]3aratively  large  quantity ;  although 
we  should  not,  nor  is  there  any  reason  to,  deny  the  importance 
of  the  components  found  merely  m  minimal  proportion.  It  is 
quite  likely  that  some  differences  in  the  action  of  the  various 
waters  depend  on  these  latter,  though  there  may  be  similar  com- 
position as  to  the  quantity  and  quality  of  their  chief  mgredients. 

You  have  been  taught  by  pharmacology  the  pharmaco-dyna- 
mics  of  these  chief  mgredients.  I  will  only  remind  you  of 
what  is  most  important  for  an  understanding  of  the  therapeu- 
tic action  of  mmeral  water. 

Water  increases  all  the  secretions ;  if  warm,  it  particularly  in- 
creases perspiration  ;  if  of  lower  temperature,  then  the  urine,  bile, 
etc  :  b}'  mcreasmg  secretion  it  influences  the  animal  metabolism. 
Cold  water  causes  increased  peristalsis  in  the  gastro-intestinal 
canal,  removes  constipation,  but  may  tend  to  cause  diarrhoea  and 
pams,  mtestinal  and  gastric,  whereas  warm  water,  on  the  con- 
trary, soothes  the  pains  and  diminishes  the  diarrlirea. 

The  action  of  carbonic  acid.  Avhether  free  or  liberated  from  the 
-carbonates,  in  the  stomach,  is  similar  to  that  of  cold  water  in  the 
gastro-mtestinal  canal :  it  increases  peristalsis,  removes  constipa- 
tion, but  may  also  cause  diarrhcea,  pains  and,  at  times,  vomiting. 

It  is  the  hicarhonate  of  soda  and  the  sodium  chloride  which  are 


—  91  — 

the  principal  curative  ingredients  of  the  alkalme  mineral  waters, 
as  proven  by  the  experience  of  centuries.  The  mechanism  of 
their  action  is  not  wholly  known.  We  know  this  much :  first, 
they  assist  m  dissolving  and  removmg  the  mucus  ui  catarrhal 
conditions,  an  effect  which  is  of  very  great  importance.  In 
gastric  catarrh  the  mucus  prevents  the  access  of  food  to  the 
mucous  membrane,  so  that  this  is  stimulated  to  a  lesser  degree 
by  the  food,  and  consequently  secretes  the  gastric  juice  less 
actively,  which  in  its  turn  reaches  the  food  less  readih'  on  ac- 
count of  the  mucus ;  on  removuig  this,  the  normal  condition  is 
reestablished.  In  catarrhal  conditions  of  the  respiratory  tract 
the  accumulated  mucus  causes  difficulty  in  breathing,  coughmg, 
etc.  The  excellent  action  of  the  combmations  of  sodium  men- 
tioned is  not  limited  to  the  removal  of  mucus  only,  but  we 
know  nothing  more  of  an  exact  nature.  Secondly,  they  uicrease 
the  secretion  of  the  gastric  and  other  alimentary  juices,  of  the 
urine,  etc.  They  alter  secretions  ;  for  mstance,  they  convert 
a  strongly  acid  urine,  with  uric  acid  sediments,  into  a  slightly 
acid,'  neutral  or  even  alkalme  one,  and  thus  they  j^revent  the 
formation  of  fresh  gravel  and  assist  m  dissolving  and  removing 
that  already  formed.  They  very  likely  act  m  a  similar  manner 
on  the  bile.  Thirdly,  in  small  quantities  they  act  favorably  on 
nutrition  (contrariwise  m  large  quantities,  —  of  this  later),  di- 
mmishmg  the  quantity  of  the  excreted  nitrogen.  To  both  bicar- 
bonate of  soda  and  sodium  chloride  a  similar  action  is  ascribed, 
especially  as  the  bicarbonate,  on  reaching  the  stomach,  must  be 
converted  mto  sodium  chloride  in  the  presence  of  the  free 
hj'drochloric  acid  of  the  gastric  juice.  But  bicarlx)nate  of  soda 
is  particularly  valuable  m  practice,  as  principally  those  waters 
are  used  mternally  —  in  catarrhal  conditions,  l3iliary  calculi, 
renal  gravel,  gout,  diabetes  mellitus,  etc.,  —  which  contain  the 
bicarbonate,  usually  also  the  sodium  chloride  ;  and  not  the  ones 
containmg  any  sodium  chloride  without  the  bicarbjnate  of  soda. 
The  laxative  salts  increase  peristalsis  and  may  cause  a  trans- 
udation from  the  mucous  membrane  of  the  intestines.  By 
emptyhig  the  mtestmes,  m  cases  of  constipation,  they  cause  a 
dimmution  in  the  size  of  the  abdomen,  facilitate  breathing  and 
circulation,   which  is  very  beneficial  in  difficult  circuktion  of 


—  92  — 

the  head,  and  chest.  Decreasing,  by  the  aid  of  laxation,  the 
absorption  by  the  intestines,  and  invitmg  a  transudation  from 
their  mucous  membrane,  they  diminish  the  fulhiess  of  the  portal 
venous  system  (which  action  may  be  very  serviceable  in  certain 
liver  troubles),  and  of  the  venous  system  in  general ;  they  also 
influence  nutrition  and  reduce  obesity. 

The  following  table,  compiled  by  me  from  the  most  reliable 
analyses  obtainable,  so  kindly  placed  at  my  disposal  by  Dr.  A. 
I.  Tsherbakoff,  shows  the  total  amomit  of  the  solid  components, 
and,  separately,  the  amount  of  those  that  are  found  in  large  (m 
heavy  type)  and  medium  (in  ordinary  type)  proportions  (the 
very  small  components  are  omitted  so  as  not  to  impair  the  gen- 
eral aspect  of  the  table)  in  the  mineral  waters  which  we  have 
selected  for  comparison,  as  well  as  in  the  bitter  ones.  The  table 
also  shows  the  quantity  of  carbonic  acid  contained  in  the  various 
mineral  waters,  and  their  temperature  in  degrees  of  both  Reau- 
mur and  Fahrenheit.  The  carbonic  acid,  whether  free  or  com- 
bined, is  shown  in  its  total  amount,  because  when  in  the  stomach, 
if  combined,  it  will  be  liberated  under  the  influence  of  the 
hydrochloric  acid  of  the  gastric  juice. 

As  regards  the  temperature  of  the  water,  I  will  say  this : 
some  of  you  will  probably  practice  at  the  places  where  mineral 
springs  are  located,  but  the  majority  will  doubtless  employ 
imported  waters  (patients  are  not  very  frequently  sent  to  the 
watering  places).  The  imported  waters  have  not,  of  course, 
their  natural  temperature,  but  that  of  the  surroundings  m  which 
the  vessel  containing  them  is  placed.  Nevertheless,  the  table 
shows  the  natural  temperature  of  the  waters,  that  long  years  of 
observation  have  shown  to  be  so  very  important  a  part  of  their 
efificacy.  What  shall  be  the  exact  temperature  of  the  water  we 
are  employing  in  the  given  case  will  be  explamed  later  on. 
I  will  only  state  now,  that  even  while  employing  the  waters  at 
their  source  the  extremes  of  their  natural  temperatures  are  to  be 
avoided ;  as,  for  mstance,  in  case  of  a  too  low  temperature,  like 
that  of  the  Marienbad  Kreuzbrunnen  (53.1°i^.),  the  water  re- 
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of  the  hot  Karlsbad  spring,  the  water  is  allowed  to  cool.  But 
at  the  same  time,  the  Marienbad  water  is  used  and  prescribed 


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—  94  — 

because  of  its  being  comparatively  cold,  and  tlie  Karlsbad  for 
its  being  a  comparatively  warm  water,  and  the  benefit  obtained 
by  the  use  of  these  waters,  as  shown  by  experience,  depends  on 
their  being  used  at  the  above  temperatures.  In  prescribing 
the  temperature  of  the  imported  waters  we  must  also  be  guided 
by  these  experiences, 

Havmg  become  familiar  with  the  composition  of  the  mmeral 
waters  selected  by  us  for  comparison,  let  us  see  why  we  ordered 
for  our  patient  the  Ems  water  and  why  we  consider  it  more 
suitable  for  our  case  than  any  other  water. 

The  diagnosis  has  showni  our  patient  to  be  suffering  from  a 
chronic  gastro-intestinal  catarrh,  m  a  state  of  exacerbation  just 
before  he  was  admitted  to  our  clinic,  from  biliary  calculi,  renal 
colic,  oxaluria,  extreme  failure  of  nutrition  and  of  physical  de- 
velopment, and  from  consequent  nervous  disturbances  of  a 
temporary  nature.  He  chiefly  comj)lained,  on  admission,  of  gen- 
eral weakness,  of  pains  m  the  abdomen  and  of  a  diarrhcBa. 

As  can  be  judged  by  the  table,  the  advantages  of  Ems  water 
for  such  a  patient  are  at  once  apparent :  the  warm  temperature 
of  the  water  is  very  beneficial  in  pains  and  in  diarrhoea ;  the 
moderate  quantity  of  bicarbonate  of  soda  and  of  sodium  chloride 
is  much  more  suitable  for  pams,  diarrhoea  and  failure  m  nutri- 
tion, than  a  large  amount,  as.  for  instance,  that  amount  of  the 
bicarbonate  in  Vichy  and  Yessentucki,  and  of  the  chloride  in 
Kissingen ;  then  the  trifling  amount  of  other  component  parts 
besides  the  principal  ones  (the  Kesselbrunnen  spring  contains, 
out  of  the  total  amount  of  35.5  of  solid  parts  per  10,000,  30.2 
parts  of  bicarbonate  of  soda  and  sodium  chloride,  so  that  on  the 
rest  fall  but  5.3  parts)  is  always  of  great  importance,  and  espe- 
cially so  in  a  case  like  ours,  where  the  stomach  and  the  intestmes 
are  so  severel}^  affected,  because  such  "  pure  "  mineral  watei"S 
are  much  easier  borne  than  waters  of  an  opposite  composition. 

The  course  of  the  illness  has  proved,  as  you  know,  that  we 
were  not  m  error  in  prescribing  Ems  for  our  patient.  Let  us 
consider  now  what  would  have  been  the  action  of  other  mineral 
waters  m  the  present  case. 

Marienbad  is  evidently  contra-indicated,  —  first,  because,  being 
a  cold  water  (53.1°i^.),  it  would  aggravate  the  diarrhciea  and 


—  95  — 

all  the  pains ;  and  secondh^,  containing,  as  it  does,  great  quan- 
tities of  sodium  sulphate  (49.5  per  10,000),  it  would  act  as  a 
strong  laxative. 

The  same  must  be  said  of  Franzenshad,  which  is  also  a  cold 
(51.8°i^.)  water,  and  which  also  contains,  although  in  a  smaller 
amount,  sodium  sulphate  (28.0  per  10,000). 

Kissingen  is  contra-indicated  in  our  patient  for  many  reasons  : 
it  is  also  a  cold  water  (51.8°^.),  but,  although  the  sodium  sul- 
phate is  absent,  it  contains  such  a  quantity  of  the  sodium  chloride 
(58.8  per  10,000)  that  it  acts  as  a  laxative,  the  more  so  as  it 
also  contains,  small  though  the  quantity  be,  some  magnesium 
sulphate,  a  strongly  laxative  salt ;  finally,  it  contains  no  bicar- 
bonate of  soda,  but  on  the  contrary  a  great  deal  of  lime  salts 
(15.3  per  10,000). 

Karlsbad^  with  one  important  exception,  is  very  similar  to 
Ems:  it,  too,  is  a  warm  (135.8°i^.)  water,  containing  the  same 
amount  of  sodium  bicarbonate  (18.1  per  10,000)  and  sodium 
chloride  (10.3  per  10,000)  as  Ems.  It  is  also  a  very  pure 
water ;  but  among  the  chief  component  parts  it  contams  a  con- 
siderable quantity  of  sodium  sulphate  (23.9  per  10,000)  —  a 
laxative  salt.  Some  physicians  employ  Karlsbad,  as  a  warm, 
or  hot,  water,  and  in  diarrhoea. 

In  cases  where  the  constipation  is  alternated  often  by  diar- 
rhoea, but  where  the  first  usually  iDredominates,  I  have  had 
opportunity  to  see  some  successful  results  with  the  Karlsbad ; 
but  for  cases  similar  to  that  of  our  patient  I  positively  prefer 
the  Ems. 

Vichy.  —  The  Celestins  spring  is  cold  (53.6°JP.)  and  con- 
sequently unsuitable  for  our  patient.  The  Grande  Grille  sprhig 
is  very  similar  to  Ems  :  the  water  is  also  warm  (105. 8°i^.),  does 
not  contain  any  laxative  salts  (except  a  trifling  quantity  of 
sodium  sulphate),  is  also  very  pure,  but  has  a  greater  quantity 
of  sodium  carbonate  (48.8  per  10,000),  and  is  therefore  contra- 
indicated  in  our  patient,  or  is  at  least  less  suitable  for  him  than 
Ems,  partly  because  of  his  diarrhoea,  but  principally  on  account 
of  the  extreme  failure  in  his  nutrition.  The  long-continued 
use  of  great  quantities  of  bicarbonate  of  soda  has  been  shown 
by  clinical  investigations  and  experimental  data  to  injuriously 


—  96  — 

affect  the  nutrition,  especially  in  patients  as  emaciated  as  ours 
is. 

The  Yessentucki  springs  are  cold,  contain  even  more  bicar- 
bonate of  soda  than  the  Vichy  springs,  and  also  a  great  deal  of 
sodium  chloride,  and  are  therefore  even  more  contra-indicated  in 
our  patient  than  those  last,  on  account  of  the  diarrhoea  and  of 
the  failure  in  nutrition. 

Obersahbrunnen  ("  Silesia  water"  )  approaches  Ems  in  the 
quantity  of  the  bicarbonate  of  soda  (21.6  per  10,000),  but  is 
unsuitable  for  our  patient  because  it  is  a  cold  water  (47.3°i''.), 
containing  a  great  deal  of  carbonic  acid  (38.1  per  10,000),  and, 
although  in  a  small  quantity,  also  sodium  sulphate  (4.6  per 
10,000),  and  is  consequently  liable  to  aggravate  the  diarrhoea 
and  the  pains.  I  will  take  occasion  to  say  a  few  words  con- 
cernmg  the  employment  of  Ems  and  Obersalzbrunnen  in  diseases 
of  the  respiratory  tract,  in  which  these  waters  are  used  more 
frequently  than  any  others ;  I  will  do  so  now,  so  that  I  may  not 
have  to  touch  upon  this  subject  later  on  when  we  come  across 
patients  suffering  from  these  diseases.  The  Ems  waters,  from 
the  Kranchen  and  Kesselbrunnen  springs,  are  employed  at 
their  location  in  the  following  manner :  Kranchen  for  diseases  of 
the  organs  situated  above  the  diaphragm,  and  Kesselbrunnen  in 
diseases  of  parts  below  the  diaphragm.  The  reason  for  this  is 
evident :  in  the  diseases  of  organs  below  the  diaphragm,  as  we 
see  it  so  well  exemplified  m  our  patient,  with  his  (on  admission) 
torturing  pains  and  diarrhoea,  the  warmer  Kesselbrunnen  (37.3° 
i2.,  116°^.)  is  more  suitable  than  the  cooler  Kranchen  (28.7°-R., 
87.8°i''.)  ;  on  the  contrary,  in  diseases  of  "  parts  above  the  dia- 
phragm," namely,  of  the  respiratory  organs,  Kranchen  is  more 
suitable,  because  the  much  warmer  water  of  the  Kesselbrunnen 
might  rather  tend  to  call  out  haemoptysis.  In  the  imported 
Ems  water  there  is  certainly  no  such  difference  in  the  temper- 
ature of  Kranchen  and  Kesselbrunnen,  and  they  can  therefore 
both  be  used  indifferently,  in  view  of  the  similarity  of  their  com- 
position, heating  them  up  to  the  temperature  required  by  the 
presenting  case. 

Sms  and  Obersalzbrunnen.  —  Ems  is  usually  prescribed  in  ca- 
tarrhal conditions  of  the  respiratory  tract,  Obersalzbrunnen  in 


—  97  — 

tuberculous  affections  of  the  same :  thus  in  the  ordmary  most 
frequent  form  of  tuberculosis  of  the  lungs,  that  is,  in  chronic 
tuberculous  broncho-pneumonia.  Ems  is  not  prescribed  for 
tuberculosis  pulmonum  for  fear  of  causing  h^emoptj^sis.  The 
cause  of  hsemoi^tysis  when  brought  on  by  the  employment  of 
Ems  in  patients  suffering  with  pulmonary  tuberculosis,  is  to  some 
extent  found  in  the  very  locality  of  Ems,  which  is  reij  .warm 
during  summer  ;  while  the  locality  where  Obersalzbrunnen  is  sit- 
uated is  much  cooler.  Another  cause  lies  m  the  fact,  that  Ems, 
bemg  warm  and  containing  less  of  carbonic  acid,  rather  tends  to 
constipate,  and  constipation  creates  a  predisposition  to  heemop- 
tysis  ;  whereas  Obersalzbrunnen,  being  cold  and  contaming  a  great 
deal  of  carbonic  acid  and  also  little  of  a  laxative  salt  (sodium 
sulphate),  is  rather  of  a  laxative  nature.  When  using  the  im- 
ported Ems  and  Obersalzbrunnen  waters,  the  differences  of 
locality  and  temperature  are  of  coui'se  not  taken  mto  account, 
and  both  waters  may  be  employed  mdifferently  for  catarrh  and 
tuberculosis  of  the  respu-atory  organs,  Obersalzbrunnen  being 
prescribed  for  cases  mclmed  to  constipation,  and  Ems  for  those 
with  a  tendency  to  diarrhoea. 

As  has  been  explamed  above,  the  Contrexeville  water,  contain- 
ing lime,  would  be  the  most  suitable  for  the  oxaluria  and  renal 
colic  in  our  patient,  but  as  it  would  tend  to  prolong  the 
diarrhoea  we  were  compelled  to  abstain  from  employmg  it  and 
had  to  resort,  m  combating  the  above-named  diseased  conditions, 
to  the  use  of  the  alkalme  Ems  waters. 

It  becomes  apparent  from  the  above,  why  we  preferred  above 
others  the  Ems  water  for  our  patient;  but  to  make  still 
clearer  the  matter  of  selecting  mineral  waters  and  at  the  same 
time  to  characterize,  even  to  a  slight  extent,  the  most  important 
of  those  selected  by  us  for  comparison,  I  shall  again  return  to 
this  subject  m  the  next  lecture. 


LECTURE  OF  OCTOBER  13,  1889. 

Condition  of  the  patient.  —  A  week  has  passed  since  we  saw 
the  patient  last  time.  Durmg  this  week  he  continued  takino- 
the  warm  Ems   water  (one  and  one-half  glasses  per  day),  the 


—  98  — 

decoction  of  condurango  with  drops  of  nux-vomica,  drops  of 
coto,  and  wine ;  continued  taldng  baths  at  times  and  had  mas- 
sage constantly.  The  patient's  condition  is  steadily  improving. 
The  quantity  of  food  is  slightly  increased  by  the  addition  of  a 
glass  of  milk  and  of  about  one-fourth  of  a  pound  of  white 
bread,  and  the  food  itself  is  somewhat  changed;  on  account  of 
the  difficulty  in  obtainmg .  fresh  eggs,  they  were  discontinued 
and  replaced  by  an  additional  quantity  of  chicken  meat.  The 
patient  gets  now  per  diem  the  following :  about  one  poruid  of 
white  bread  (the  whole  bread  with  the  crust  is  eaten),  one-half 
chicken,  two  meat  cutlets,  two  glasses  of  soup  with  broken  up 
meat,  two  glasses  of  milk  soup  with  manna,  and  three  glasses  of 
milk  with  cognac.  This  quantity  of  food  is  digested  by  the 
stomach  without  any  dyspeptic  phenomena.  The  intestinal 
evacuations  once  a  day,  the  first  days  after  the  third  half-glass 
of  Ems  was  added,  were  formless  and  even  somewhat  liquid, 
however  without  pams  on  defecation,  but  these  last  few  days 
they  again  became  quite  solid,  although  the  patient  contmues, 
as  I  said,  drinkmg  three  half-glasses  of  the  water.  The  abdo- 
men is  not  distended.  The  spontaneous  pains  appear  only  at 
the  side  of  the  left  kidney,  more  frequently  on  motion,  and  are 
weaker  than  formerly.  Examination  of  the  abdomen  also 
elicits  tenderness  only  on  the  side  of  the  left  kidney ;  at  the 
other  places,  among  them  m  the  region  of  the  gall-bladder  and 
sigmoid  flexure,  where  a  week  ago  pressui-e  elicited  tenderness, 
there  is  at  present  neither  sensitiveness  nor  tenderness  to  be 
noted.  The  urine  became  normal,  —  it  is  neither  pale  nor  turbid, 
outside  of  the  usual  and  normal  slight  cloudiness  due  to  mu- 
cus, and  gives  absolutely  no  sediment  of  calcium  oxalate  crys- 
tals. The  pulse  continues  strong.  Patient  keeps  gainmg  m 
weight,  the  latter  being  no\v  ninety-eight  pounds  (seven  pounds 
more  than  he  weighed  on  admission).  His  sleep  is  satisfactory, 
his  strength  grows  steadily. 

After  what  was  said  of  the  plan  of  treatment  and  in  view  of 
the  just  enumerated  results  of  this  last,  it  is  evident  that  noth- 
ing is  to  be  changed  as  yet  in  the  treatment.  The  di'ops  of 
coto  must  be  continued  till  the  mtestinal  evacuations  become 
normal  —  steadily,  without  oscillations  ;  the  dose  of  these  drops 


99  — 


must  be  slightly  increased,  as  the  patient  could  become  habitu- 
ated to  them ;  instead  of  fifteen  drops  as  heretofore  he  will  be 
given  twenty  drops  three  times  a  day. 


I  return  to  the  mineral  waters. 

In  what  cases  is  Marienhad  to  be  prescribed  ?  This  water  in 
the  quantity  of  bicarbonate  of  soda  (16  per  10,000)  and  of 
sodium  chloride  (17  per  10,000)  approaches  Ems  water,  but  con- 
tains a  great  quantity  of  a  laxative  salt,  sodium  sulphate 
(49.5  per  10,000)  and  besides  it  is  a  cold  water  (53.1°!'.). 
I  will  attempt  to  give  you  a  description  of  typical  patients  who 
require  treatment  by  Marienbad.  They  are  usually  people  of 
good  constitution,  over  forty  years  of  age,  well-to-do,  leading 
generally  an  mdoor  life,  brain-workers ;  their  amusements 
(readmg,  cards,  theatre,  society)  also  of  a  mental  character, 
with  little  out-door  exercise,  —  mostly  city  inhabitants.  The 
followmg  collection  of  diseased  phenomena  is  usually  to  be 
found  with  them :  1st,  considerable  dyspeptic  phenomena  — 
prmcipally  constant  or  frequently  occurrmg  symptoms  of  an 
over-loaded  stomach  (due  usually  to  a  temporary  overdistention 
of  the  organ,  and  not  to  an  established  dilatation  of  the  same)  : 
a  feeling  of  fulness  and  heavmess  m  the  epigastrium,  belch- 
ing, often  pamful,  with  a  sensation  of  burning,  of  gases,  liquids, 
or  of  mostly  undigested  food ;  but  constant  and  severe  pains, 
as  well  as  vomiting,  are  usually  absent.  Investigation  ordmarily 
finds  the  causes  of  this  condition  to  be  m  the  majority  of  cases 
as  follows  :  the  patient  over-eats  constantly ;  being  well-to-do, 
he  usually  has  very  palatable  food,  often  also  wine,  and  he  there- 
fore eats  much  more  than  is  plainly  necessary  for  satisfying 
hunger ;  added  to  this  is  a  nervous  dyspepsia,  as  the  patient 
is  either  a  neurasthenic,  or,  as  we  shall  see  later,  becomes  such; 
oftentimes  there  is  also  associated  with  this  a  gastric  catarrh, 
but  such  is  usually  trifling,  without  pain  or  vomiting.  Then 
such  patients  usually  suffer  from  a  constant  constipation  (or  at 
least  from  an  insufficient  emptying  of  their  bowels),  partly  on 
account  of  their  neurasthenia,  partly  because  of  the  distended 
stomach,   that   is   on  account  of  the   retarded  passage  of  the 


—  100  — 

gastric  contents  into  the  intestines.  The  abdomen  is  distended, 
the  cliaphi'agm  is  pushed  upward.  The  urme  is  more  colored 
than  normally,  and  gives  frequently  some  uric  acid  sediments. 
There  appear  at  times  slight  symptoms  of  renal  colic,  and  some 
gout}-  pains  in  the  small  articulations.  The  liver  is  usuUy 
enlarged  and  sensitive  on  account  of  hypersemia.  Tliis  latter 
is  due  either  to  the  fact  that  the  patient  is  addicted  at  the 
same  time  to  alcoholic  drinks,  or  because  the  passage  of  the 
food-stuffs  from  the  intestmal  canal  into  the  vente  portee  is 
more  abundant  than  normally,  or,  as  some  suppose,  also  because 
these  stuffs  contain  a  great  number  of  ptomames  (which  are 
also  supposed  to  cause  a  h}^jer?emia  of  the  liver),  which  in 
such  a  condition  of  digestion  are  produced  in  abundance  by  the 
usual  microbes  of  the  stomach  and  of  the  intestmes.  There  are 
at  times  also  produced  slight  symptoms  of  liver  colic.  The 
organs  of  resphation  are  either  normal  or  there  is  a  slight 
catarrhal  condition  of  the  upper  respirator}^  organs ;  the  organs 
of  circulation  are  either  healthy  or  present  some  slight  signs  of 
a  chi'onic  arteritis.  The  patients,  however,  usually  complain  of 
dyspnoea  and  palpitation,  which  may  in  part  be  due  to  purely 
mechanical  causes,  as  the  high  position  of  the  diaphragm,  or 
partly  to  reflex  action,  through  the  nervous  system,  by  the 
abdommal  disturbances,  and  perhaps  on  account  of  the  above 
mentioned  ptomaines.  The  patients  are  usually  not  lean,  but 
stout,  and  sometimes  even  obese ;  they  usually  complain  of 
"  influxes  of  blood  to  the  head,"  or  of  the  followmg  morbid 
symptoms  (partly  simply  of  a  vasomotor  origm,  partly  probably 
of  ptomaine  origin)  :  a  feeling  of  heat  in  the  head,  flushed 
face,  a  general  heavmess  in  the  head,  at  times  pam  at  the 
nape  of  the  neck,  clizzmess,  troublesome  sleep,  fatigue  while 
employed  mentally,  and  an  irritable  and  somewhat  gloomy  men- 
tal state.  Such  patients,  if  they  were  not  neurasthenic  before, 
become  such  now  to  a  greater  or  lesser  extent,  on  account  of 
the  above-mentioned  abdominal  and  mental  disturljances,  es- 
pecially under  the  influence  of  the  above-described  mode  of 
living.  If  this  morbid  condition  is  not  clearly  defined  as  yet, 
being  only  in  the  begmning  of  its  development,  then  it  is,  of 
course,  possible  to  bruig  the  patieiit  to  his  normal  healtii  by  the 


—   101  — 

aid  only  of  a  strictly  regulated  diet.  But  if  this  condition  be 
completely,  even  if  not  extremel}-  developed,  then  it  would  be 
erroneous  to  attempt  to  improve  the  patient's  condition  hy  hy- 
giene only,  without  a  resort  to  treatment :  it  is  doubtful  whether 
such  an  improvement  could  ever  be  reached;  at  any  rate  only 
after  a  considerable  length  of  time,  in  the  course  of  which  the 
patient  would  remain  needlessly  in  a  very  unsatisfactory  or  even 
painful  condition.  It  is  here  that  we  must  prescribe  Marien- 
bad  in  connection,  of  course,  with  hygiene. 

Before  we  speak  of  the  action  of  Marienbad,  let  us  consider 
what  would  be  the  action  of  Ems  in  such  a  case.  Being  a 
warm  water  and  not  containing  any  laxative  salts,  Ems  would 
tend  to  costiveness,  thus  aggravating  the  constipation,  and,  on 
being  absorbed,  would  increase  the  overloading  of  the  vena 
portffi  and  the  hyperfemia  of  the  liver ;  as  a  consequence  both 
the  chest  and  chiefly  the  head  sjaiiptoras  would  become  aggra- 
vated. Whereas  Marienbad,  bemg  a  cold  water  and  contaming  a 
laxative  salt,  if  used  correctly  in  quantities  sufficient  to  cause 
abundant,  gruel-like  evacuations  (but  not  watery,  of  which 
later ^,  would  sufficiently  empty  the  gastro-mtestinal  canal  and 
would  thus  remove  the  above-named  consequential  disturbances. 
If  the  Marienbad  water  be  administered  correctly,  that  is,  so  as 
to  produce  abundant,  gruel-like  evacuations,  but  not  always 
watery,  then  it  is  likely  that  its  bicarbonate  of  soda  and  its 
sodium  chloride  are  absorbed  either  completely  or  j)aTtially, 
because  with  the  general  improvement  of  the  patient  the  former 
slight  sjanptoms  of  liver  and  kidney  colic,  as  well  as  the  gouty 
symptoms,  are  seen  to  disappear.  Patients,  especially  if  obese, 
grow  thin  by  the  use  of  Marienbad. 

If  ni  addition  to  the  use  of  Marienbad,  there  is  also  a  radical 
change  instituted,  even  for  a  short  time,  in  the  mode  of  living 
and  in  the  surrounding  circumstances  ;  as,  for  mstance,  a  trip 
to  Marienbad  itself,  and  later,  to  combat  the  neurasthenia,  a 
trip  to  the  sea-bathmg  places  (for  those  who  are  younger,  to  the 
more  northern  ones,  as  Lamanche  or  the  Baltic  Sea ;  for  the 
older  ones  —  to  Biarritz  or  the  Black  Sea),  or,  without  leaving 
the  immediate  localit}'-,  a  removal  from  the  citj^  to  the  country 
(m  connection  with  this,  Marienbad  is  taken  in  May,  while  the 


—  102  — 

•  younger  patients  bathe  in  the  river  during  June  and  July,  and 
the  older  ones  take  salt-baths  at  a  temperature  of  27°R.  and 
lower),  then  the  result  of  such  a  treatment  may  be  a  complete 
return  to  health ;  —  the  patients  feel  rejuvenated.  If,  besides, 
the  physician  be  careful  and  strict  in  his  requirements  and  make 
it  clear  that  the  obtamed  result  can  be  lastmg  only  m  case  the 
hygienic  rules  are  strictly  adhered  to,  and  the  former  careless 
mode  of  life  is  avoided,  then  the  issue  will  be  perfectly  satis- 
factory, especially  if  the  patient  possess  a  strong  will  and  be 
careful  of  his  health.  In  the  contrary,  unfortmiately  more 
frequent,  cases,  when  the  patient  falls  back  to  his  irregular 
hygienic  habits,  a  repetition  of  the  Marienbad  or  of  some  other 
similar  water  becomes  necessary.  These  repetitions  do  not,  of 
course,  give  the  same  satisfactory  results,  as  when  the  water 
was  used  the  first  time,  and  besides  a  repeated  and,  particularly 
frequent,  employment  of  mineral  water  is  not  without  its  un- 
doubted harm,  for  it  deranges  digestion  and  nutrition. 

What  would  be  the  action  of  the  Vichy  sprmgs  on  a  case,  as 
described  above,  so  suitable  for  Marienbad?  Grande  Grille, 
being  a  warm  water  and  containing  almost  no  laxative  salts, 
would  aggravate  the  constipation  and  with  this  also  the  con- 
dition of  the  patient.  The  cold  Celestms  would  be  less  consti- 
pating ;  but  not  contamuig  any  laxative  salts,  it  would  not  act 
upon  the  bowels  sufficiently  and  would  consequently  be  inferior 
to  Marienbad.  In  such  cases  it  is  the  degree  of  costiveness 
that  decides  the  choice ;  if  the  tendency  to  constipation  is  not 
great,  then  even  the  cold  Celestms  will  act  as  a  laxative,  if 
assisted  by  a  temporary  or  a  frequent  use  of  a  small  quantity  of 
some  bitter,  so  that  together  they  will  exert  an  effect  approxi- 
mating the  action  of  Marienbad ;  (the  other  diseased  conditions, 
outside  of  constipation  and  its  consequences,  found  in  a 
patient  described  above,  as  the  dyspeptic,  liver  and  kidney 
symptoms,  will  be  certainly  favorably  acted  upon  by  the  Celes- 
tms, so  rich  in  bicarbonate  of  soda).  This  latter  is  then  evident- 
ly better  mdicated  for  such  patients  than  Vichy. 

What  would  be  the  action  of  the  Karlsbad  spruigs  on  such  a 
patient?  They  contam  sodium  sulphate,  but  in  half  the 
quantity,  contained  by  Marienbad,  and  besides  they  are  partly 


—  103  — 

warm  and  partly  hot :  the  warmth  of  the  water  may,  especially 
m  conditions  of  constipation,  inhibit  the  laxative  action  of  the 
moderate  quantity  of  the  sodium  sulphate  and  consequently,  by 
aggravating  the  costiveness  or  its  effects  (particularly  the  head 
symptoms),  will  aggravate  the  patient's  condition  or  at  least  by 
not  inducing  a  sufficient  evacuation  of  the  bowels,  it  will  not 
produce  the  necessary  curative  effect. 

A  few  words  regarding  the  indication  for  Kissingen.  It  has 
much  ui  common  with  that  for  Marienbad,  because,  although 
Kissmgen  does  not  contain  any  sodium  sulphate  and  but  a  little 
(5.9  of  the  10,000  parts)  of  magnesium  sulphate,  it  still  is  a  laxa- 
tive, thanks  to  its  low  temperature  (51.8°i^.),  the  great  amount 
of  carbonic  acid  (30.4  per  10,000)  and  the  enormous  quantity  of 
sodium  chloride  (58.8  per  10,000).  But  the  laxative  action  of 
Kissingen  is  not  as  strong  as  that  of  Marienbad,  and  it  is  there- 
fore suitable  for  such  patients  as  were  described  in  discussing 
Marienbad,  but  somewhat  older  and  not  m  the  best  of  nutrition  ; 
besides,  also  for  such  patients  as  do  not  present  any  clearly  ex- 
pressed indications  for  the  use  of  bicarbonate  if  soda  (as  uric 
acid  gravel,  etc.),  as  this  last  is  absent  in  the  Kissingen  water. 

For  what  cases  is  Karlsbad  prescribed  ?  Principally  for  severe 
gastric  catarrh,  accompanied  by  pains  and  vomitmg,  and  for 
severe  liver  colic,  depending  on  biliary  calculi;  m  both  such 
cases  there  is,  to  a  greater  or  lesser  extent,  constipation,  or  con- 
stipation mtermittent  with  diarrhoea  of  short  duration ;  but  this 
latter  is  neither  constant  nor  considerable  (for  such  a  case,  as 
was  explained  above,  we  would  employ  Ems).  The  warm  or 
even  the  hot  water  of  the  Karlsbad  springs,  contaming  a  moder- 
ate amount  of  sodium  bicarbonate,  of  sodium  chloride  and  of 
sodium  sulphate,  and  as  little  of  the  remainmg  mgredients  as  the 
water  of  the  Ems  springs,  and  being  just  as  "|?w,re,"  acts  splen- 
didly in  the  above  mentioned  cases.  Marienbad  would  evident- 
ly be  unsuitable  for  such  cases,  because,  being  a  cold  water,  it 
would  tend  to  aggravate  the  gastric  pains,  the  vomiting  and  even 
the  attacks  of  the  liver  colic,  or  because  it  would  purge  the  pa- 
tient strongly ;  whereas  in  these  cases  severe  purgmg  is  posi- 
tively undesirable,  as  it  hmders  the  treatment,  while  our  aim  is 
to  empty  the  bowels  regularly  ;  this  would  not  prevent  absorption 


—  104  — 

and  consequently  the  further  action  of  the  mmeral  alkaline 
water  on  bile,  biliary  calculi  and  also  on  the  urine  and  urinary 
gravel,  if  such  is  to  be  found  at  that  time.  On  the  contrary, 
Vichy,  namely,  the  warm  Grande  Grille,  which  would  be  suitable 
in  such  cases  because  of  its  warmth  and  of  the  abundance  of  its 
sodium  bicarbonate,  is  contra-indicated  by  the  constipation,  that 
particularly  aggravates  the  head  symptoms,  because,  not  contam- 
ing  any  laxative  salts,  the  water  would  aggravate  the  constipa- 
tion and  its  consequences.  The  same  must  be  said  of  Ems.  In 
the  above  described  cases  where  Karlsbad  is  indicated,  if  the  con- 
stipation be  severe  and  the  head  symptoms  considerable,  then  a 
laxative  salt  (usually  the  "  Karlsbad  "  salt  itself,  obtamed  from 
Karlsbad  water  and  containing  sodium  sulphate)  is  added  to  the 
water ;  while  m  old  persons,  in  whom  there  may  be  any  apprehen- 
sion of  apoplexy,  derivative  bloodlettmg  is  to  be  resorted  to, 
leeches  applied  to  the  region  of  the  coccyx,  before  Karlsbad  is 
employed. 

A  few  words  concerning  the  indications  for  the  Fraiizensbad 
Salzquelle  (lit.  salt-spring).  Franzensbad  is  famous  for  its  min- 
eral-mud baths  (Moorbader).  Thither  flock  in  great  numbers 
women  suffermg  from  diseases  of  the  genital  organs  and  from 
failure  in  nutrition  and  strength,  and  also  exhausted  and  neuras- 
thenic men.  Such  persons  often,  almost  always,  suffer  with 
dyspeptic  symptoms,  gastric  and  mtestmal,  due  to  a  slight 
catarrh  or  to  nervous  dyspepsia,  —  usually  with  constipation,  — 
who  require  the  use  of  slightly  alkalme  and  laxative  waters. 
Salzquelle,  as  you  may  see  by  the  table,  is  just  such  a  water,  and 
is  in  addition  very  pure,  containmg,  outside  of  the  prmcipal 
ingredients,  very  little  of  other  component  parts.  Marienbad 
would  be  too  strong  for  such  patients.  Ems  is  also  unsuitable, 
as  it  would  not  remove  the  constipation.  Finally  the  cold  Salz- 
quelle is  preferred  to  the  hot  Karlsbad  for  women  with  diseases 
of  the  generative  organs,  because  of  the  liability  of  the  latter  to 
either  cause  or  to  aggravate  internal  hemorrhage. 

The  chief  indication  for  the  Vichy  springs  is  gout  (arthritis 
urica)  and  renal  gravel  (in  the  form  of  urates)  with  or  without 
dyspeptic  symptoms,  but  ^vithout  obstinate  constipation,  and 
besides  in  patients  with  a  florid,  or  at  least  a  good  nutrition. 


—   105  — 

Marienbad  would  be  unsuitable  for  such  patients,  for  acting 
as  a  laxative,  it  would  hinder  absorption  and  consequently  also 
any  further  action  of  the  alkalies ;  while  Karlsbad,  because  of 
the  warmer  temperature  of  its  water,  would  have  a  weaker 
diuretic  effect,  and  besides  would  act  as  a  laxative,  which  again 
would  counteract  its  diuretic  effect.  Finally,  Vichy  contains 
bicarbonate  of  soda  —  the  prmcipal  active  agent  for  the  above- 
named  cases  —  in  a  much  larger  amount  than  either  Karlsbad 
or  Marienbad.  However,  Karlsbad  is  prescribed  for  renal 
gravel,  as  well  as  Vichy  is  for  biliary  calculi,  we  bemg  guided, 
besides  other  considerations,  usually  by  the  fact  that  if,  in  the 
presence  of  both  the  liver  and  the  renal  colics,  the  fu\st  predomi- 
nates, then  Karlsbad  is  given,  if  the  latter  —  then  Vichy. 

Yessentucki.  —  There  is  a  generally  prevalent  opinion  to  the 
effect  that  the  Yessentucki  sprmgs  are  equivalent  to  those  of 
Vichy.  This  opinion  is  wrong;  the  number  of  indications  em- 
braced by  the  Yessentucki  springs  is  much  greater  and  much 
more  varied  than  the  number  of  mdications  for  Vichy  sprmgs. 
They  are  alike  m  the  quantity  of  the  predominant  bicarbonate  of 
soda,  although  the  Y^essentucki  springs  Nos.  17  and  18  are  richer 
m  it  than  the  A^ichy  sprmgs.  But  the  chief  difference  between 
the  springs  of  both  groups  consists  in  the  quantity  of  sodium 
chloride,  of  which  there  is  little  in  Vichy  and  much  in  the  Yes- 
sentucki. The  considerable  quantity  of  the  sodium  chloride 
imparts  to  the  Y^essentucki  sprmgs  a  laxative  action,  which  is 
lacking  in  the  Vichy  sprmgs ;  although  this  laxative  action  is 
not  as  strong  as  that  of  the  waters  contamiug  sodium  sulphate 
or  magnesium  sulphate.  We  shall  see  later  that  m  this  quality 
of  the  Y^'essentucki  sprmgs  lies  their  chief  preference.  Finally 
the  three  Yessentucki  springs,  Nos.  17,  18  and  4  (the  ascending 
stream),  so  very  similar  in  their  composition  C|ualitatively.  pre- 
sent a  considerable  quantitative  difference,  which  again  forms  a 
great  advantage,  enabling  us  to  order  this  or  that  spring,  accord- 
ing as  to  Avhether  the  case  requires  a  stronger  or  weaker  action, 
taking  into  accomit  the  degree  of  development  of  the  diseased 
conditions,  the  constitution  and  nutrition  of  the  patient. 

In  all  the  cases  for  which  the  Vichj-  sprmgs  are  prescribed  (vide 
above),  we  also  prescribe  the   Yessentucki  with  even  greater 


—  106  — 

.success,  if  there  be,  as  there  is  liable  to  be  in  the  majority  of 
cases,  a  tendency  to  constipation;  if  there  be  an  inclination 
toward  diarrhoea,  which  is  rather  of  rarer  occurrence,  then  the 
Vichy,  as  is  apparent  from  what  was  stated  above,  would  be 
more  preferable.  In  view  of  their  low  temperature  and  the 
considerable  quantity  of  the  contained  sodium  chloride  and 
carbonic  acid,  i.  e.  because  of  their  laxative  effect,  the  Yessen- 
tucki  springs  are  successfully  prescribed  for  the  same  cases,  in 
which  Kissmgen-Rakoczy  is  indicated  (vide  above),  if  there 
is  simultaneously  an  indication  for  the  introduction  into  the 
organism  of  bicarbonate  of  soda,  which  is  lacking  in  the  Kis- 
singen  spring.  With  the  aid  of  the  simultaneous  use  of  a 
small  quantity  of  some  bitter  water,  as,  for  instance,  of  the 
Maria  Theresia  spring  (near  Pyatigosk),  the  water  of  the  Yes- 
sen  tucki  sprmgs  Nos.  17  and  18  can  in  many  cases  fully  re- 
place Marienbad,  and,  when  warmed  sufficiently,  also  Karlsbad. 
For  urinary  gravel,  composed  not  of  urates,  but  of  phos- 
phates and  oxalates,  as  also  for  gouty  patients  with  failure 
in  nutrition,  in  the  so-called  atypical  gout,  the  earthy  mineral 
waters  are  indicated  ;  the  best  of  these,  as  far  as  is  known  now, 
is  ContrexeviHe,  which  I  have  already  mentioned  above. 


LECTURE  OF  OCTOBER  18,  1889. 

While  comparing  the  mineral  waters  of  which  I  spoke  above, 
I  presented  typical  examples  where  they  are  to  be  employed, 
but  I  certamly  did  not  mtend  to  exhaust  the  whole  variety  of 
cases  which  may  present  some  preeminent  indication  for  the 
use  of  this  or  that  water.  This  comparison  of  the  most  impor- 
tant mineral  waters  has  made  clear  to  you  their  chief  individual 
characteristics,  the  knowledge  of  which  will  enable  you  to 
correctly  prescribe  these  waters ;  I  repeat,  the  most  impor- 
tant waters,  because  they  have  been  the  most  investigated,  the 
most  useful,  and  because  in  the  great  majority  of  the  occurring 
cases  we  see  them  meet  all  the  indications ;  not  to  mention  the 
fact,  that  they,  as  I  said  once  already,  present  types  of  whole 
classes  of  mineral  waters.     This  comparison  has  also  made  it 


—  107  — 

clear  to  you  as  to  how  the  selection  of  a  mineral  water  for  a 
given  case  is  made,  which  knowledge  will  aid  you  in  prescrib- 
ing also  other  mineral  waters  not  discussed  by  us. 

When  speaking  of  treatment  (in  the  Introduction  to  Clmical 
Exercises)  I  pointed  out  the  mistake  of  employmg  complicated 
medication.  You  might  ask  whether  it  would  be  correct  to  use 
such  combinations  of  drugs  as  presented  by  a  mmeral  water. 
You  might  also  ask  why  I  selected  for  comparison  only  the 
foreign  waters,  except  the  Yessentucki. 

The  knowledge  of  the  effectiveness  of  the  mineral  waters  has 
been  obtained  in  a  purely  empirical  way,  at  a  remote  period, 
when  medicine  and  balneology  were  far  from  their  present  per- 
fected condition.  To  reach  this  perfection  there  were  required 
centuries  of  labor,  gigantic  progress  in  diagnostication,  general 
pathology  and  therapeutics,  as  well  as  in  the  chemical  and  clin- 
ical (and  partly  physiological)  knowledge  of  the  mineral  waters. 
These  tests  of  centuries  the  waters  stood  nobly :  the  more 
they  were  studied,  the  greater  and  not  lesser,  became  their 
importance,  until  it  is  now  enormous  as  compared  with  what  it 
was  before.  They  stand  above  comparison  with  the  various  com- 
plex decoctions,  powders,  pills,  drops,  etc.,  —  fruits  of  experience, 
but  oftener  of  the  fancy  of  the  physician,  —  fruits  of  but  ephe- 
meral existence,  as  time  shows,  burymg  them  into  oblivion. 

For  comparison  we  took  only  foreign  waters,  except  Yessen- 
tucki. We  must  first  of  all  remember  that  these  foreign  waters 
are  the  very  useful  ones,  and  that  a  familiarity  with  these  and 
the  knowledge  of  their  employment  is  just  as  necessary  as  the 
knowledge  of  the  employment  of  opium,  quinine  and  others,  and 
these  also  are  foreign  drugs.  We  have  selected  these  waters 
because  they  present  the  best  examples  known  to  us  of  a  happy 
natural  combination  of  curative  agencies,  and  because  the  indi- 
cations for  their  use  are  best  known  to  us  (it  is  for  the  same 
reason  that  we  chose  Yessentucki  from  among  our  own  waters ) . 
However,  I  do  not  in  the  least  doubt,  but  that  the  considerable 
employment  with  us  of  the  foreign  mineral  waters  is  but  a 
matter  of  temporary  duration.  I  am  perfectly  certam,  that  our 
great  land  is  very  rich  in  various  mineral  waters  possessing  just 
as  happy,  and   even   much  happier,  combinations   of  curative 


—  108  — 

forces.  Time  will  bring  it  about,  that  we  will  become  acquainted 
with  these  waters  and  that  we  will  investigate  their  composition. 
Knowing  this  last  and  the  various  combinations  which  cen- 
turies of  experience  in  foreign  waters,  and  some  experience  in 
our  o\vai,  has  shown  to  be  effective,  we  shall  soon  learn  for 
what  cases  these  our  waters  will  be  beneficial,  and  we  will  em- 
ploy them  on  the  spot  as  well  as  export  them,  mstead  of  the 
foreign  ones,  as  we  do  now. 

I  pass  now  to  the  very  important  subject  of  the  mode  of 
employ mg  the  mineral  waters  :  what  shall  be  the  daily  quantity, 
at  what  time  of  the  day  admmistered,  and  for  how  long  a 
period. 

At  the  beginning  of  my  medical  practice  the  mineral  waters 
were  employed  only  during  summer  and  the  patient  usually  de- 
parted, with  the  purpose  of  di'mkmg  them,  for  the  places  where 
the  springs  were  located.  Imported  mineral  waters  were  pre- 
scribed but  seldom.  Artificial  mmeral  waters  were  used  also 
during  summer  in  those  few  places,  so  rare  then,  where  such 
waters  were  prepared.  But  for  the  principal  object,  I  will 
repeat,  of  drinking  the  water,  summer  excursions  were  under- 
taken to  the  mineral  water  resorts. 

The  general  character  of  practice  at  that  time  was  such  that 
waters  were  used  then  in  much  larger  quantities  than  they  are 
used  now.  Dr.  Debout  d'Estrees  ("  Les  indications  aux  eaux  de 
Contrexeville,"  Paris,  1889)  mentions  the  fact  that  the  famous 
writer  Madame  Sevigne  (he  refers,  as  you  see,  to  a  long  gone- 
by  past)  was  ordered  daily  at  Yichy  12  glasses  of  the  water  of 
the  Grande  Grille  spring,  she  being  previously  bled  and  given 
a  laxative.  We  now  generally  give  less.  Dr.  Debout  d'Estrees 
is  rather  inclined  to  ascribe  this  to  the  fact  that,  a«  he  expresses 
it,  the  struggle  for  existence  has  made  our  generation  anaemic 
and  nervous.* 

Without  denying,  but  on  the  contrarj^  considering  it  quite 
probable,  that  the  percentage  of  men  of  strong  constitution  and 
health  in  certain  social  strata  is  now  smaller  than  it  was  form- 
erl}^  I  still  think  that  there  was  another  reason  for  the  former 

*  'Sos  cerveaux,  surmenes  par  le  striiggle  for  life,  nous  out  donue  I'ane- 
mie  et  les  nevroses,  que  ne  connaissaient  pas  nos  peres  (page  11). 


—  109  — 

use  of  water  iii  greater  quantities,  namely,  this  :  that  the  arrivals 
at  the  springs,  never  having  the  necessary  time  at  their  dispo- 
sal, the  physician  attempted  to  obtain  the  desired  effects  sooner, 
and  therefore  administered  the  water  m  great  quantities.  But 
at  present,  when  the  waters  are  much  more  used,  while  remain- 
ing at  one's  own  constant  residence,  this  lack  of  time,  and  with 
it  the  necessity  for  haste,  are  absent.  It  is  well  miclerstood  that 
the  progress  in  diagnosis,  general  pathology  and  therapeutics 
could  not  but  have  a  certain  influence  on  the  diminution  of  the 
prescribed  quantity  of  the  water  for  cMnking  purposes. 

However,  even  now  the  routme  method  of  drinking  the  water 
at  the  resorts  in  summer  differs  greatly  from  the  manner  in  which 
they  are  used  at  the  other  seasons  of  the  year,  and  even  now  pre- 
serves a  great  many  of  the  former  procedures.  The  water  is 
usually  drunk  m  the  early  morning,  when  it  is  not  yet  hot,  so 
that  the  prescribed  walk  to  be  taken  after  the  water  is  made  less 
burdensome ;  the  water  is  taken  on  an  empty  stomach  and  m 
lesser  quantity  than  formerly,  but  always  in  a  greater  quantity 
than  when  the  water  is  prescribed  not  in  summer,  but  at  other 
seasons  of  the  year  and  at  the  place  of  the  patient's  residence. 
Such  a  routine  treatment  often  gives  excellent  results.  Picture 
to  yourselves  a  city  mhabitant  of  strong  constitution,  who  is  habi- 
tuated to  late  rismg  and  of  course  to  retirmg  late  to  bed,  who  com- 
mits errors  in  his  diet,  lives  a  mental  life,  has  almost  no  exercise, 
and  but  seldom  goes  out  into  fresh  air, — imagme  such  a  person  lead- 
ing a  totally  different  life  at  the  w^atering  place  :  he  rises  early  and 
therefore  goes  to  bed  early,  observes  a  correct  diet,  spends  consider- 
able time  out-doors,  does  a  great  deal  of  moving  around,  rests  from 
his  mental  labor,  and  frequently,  in  addition  to  all  this,  removed 
from  the  place  of  his  permanent  residence  and  free  from  the  many 
constant  and  unpleasant  impressions,  he  drinks  the  correctly  pre- 
scribed water  and  usually  takes  his  baths  regularlj^  We  certainly 
get  in  such  cases  strikingly  good  results.  But  unfortunately  such 
is  not  always  the  case.  Routine,  that  has  always  something  of 
good  with  it,  —  namely,  that  which  created  it,  remams  but  routine, 
that  is,  it  is  at  times  beneficial,  at  other  times  harmful.  Not  to 
speak  of  the  cases,  when  the  physician's  advice  concerning  a  trip 
to  the  watering  place  is  incorrect,  when  without  individualizing 


—  110  — 

the  given  case,  without  considering  all  its  peculiarities,  he  orders 
a  trip  not  for  the  one  for  whom  it  may  be  convenient  and  bene- 
ficial, but  for  a  person  who  can  only  with  difficulty  tear  himself 
from  his  near  relatives  and  wonted  surromidings  of  life,  and  for 
whom,  besides,  such  a  trip  is  beyond  his  means.  Not  to  speak 
of  such  a  wrong  and  useless  advice  to  midertake  a  trip,  I  will 
only  point  to  the  impracticability  of  the  above  alluded  to  routine 
even  for  many  such  cases,  where  the  trip  is  both  indicated  and 
possible.  Here  is  one  of  the  cases  that  occur  quite  frequently. 
A  woman,  somewhat  exhausted  and  ansemic,  subject  to  chills, 
nervous,  and  a  poor  sleeper,  comes  to  the  watering  place  in  ac- 
cord with  the  advice  of  tlie  physician,  begins  the  above  described 
routine  method  of  living  and  of  drinking  the  waters.  She  cannot 
fall  asleep  early  m  the  evening  but  sleeps  quite  somidly  in  the 
morning  hours.  She  is  waked  up  to  go  to  the  spring,  to  take  a 
walk,  and  to  listen  to  the  inevitable  music.  Without  having 
a  good  night's  sleep  she  starts  out,  soon  becomes  chilled,  owing 
to  the  coolness  of  the  morning  air,  experiences  a  sharp  sensation 
of  hunger  and  is  soon  fatigued ;  and  in  such  a  condition  —  hun- 
gry, chilled  through  and  tired  out,  she  must  drink  a  cold  water 
and  walk  for  a  long  time.  Her  condition  has,  of  course,  become 
even  worse  than  it  was  before,  and  the  water  was  of  no  benefit. 
The  patient  then  consulted  one  of  my  former  students,  who 
lived  at  the  watering-place  and  who  was  acquainted,  tlirough  my 
clinic,  with  the  use  of  mineral  waters.  He  first  of  all  advised 
her  to  sleep  in  the  morning  as  long  as  she  felt  sleepy,  not  to 
interrupt  the  sleep,  not  to  drink  the  water  on  an  empty  stomach, 
but  after  the  morning  coffee,  before  breakfast  and  before  dinner, 
and  m  a  lesser  quantity ;  to  be  out  in  the  fresh,  open  ah,  for  a 
longer  time,  but  at  the  same  time  to  walk  only  as  long  as  her 
strength  permits  it,  and  by  no  manner  of  means  until  she  be- 
comes fatigued.     After  this  the  patient  began  to  improve. 

I  alluded  to  the  trips  to  the  watering  places  with  the 
purpose  of  acquainting  you,  at  least  to  some  extent,  with  this 
medicinal  agency,  and  to  present  examples  in  which  this  agency 
is  suitable  and  where  not,  and  finall}^  to  point  out  the  necessity, 
while  employing  this  remedy,  for  individualizing  your  cases,  so 
that  you  may  not  fall  mto  routine  habits   and  that  you  may 


—  Ill  — 

change  the  routine  order  of  living  and  of  drinking  the  waters  in 
accord  with  the  peculiarities  of  the  given  case.  I  cannot  discuss 
the  subject  much  longer,  the  more  so,  as  you  will  all  undoubtedly 
have  to  prescribe  the  mineral  water  much  of tener  for  the  patients  m 
their  places  of  residence,  without  sending  them  to  the  watering 
places.  We  will  now  endeavor  to  answer  the  questions  as  to  the 
quantity  of  the  water  to  be  used  per  day,  for  how  long  a  time,  and  at 
what  periods  of  the  day.  I  have  already  said  that  at  the  pres- 
ent day  mineral  waters  are  employed  in  lesser  quantities  than 
formerly,  but  the  manner  of  employing  them  at  the  different 
watering  places,  or  even  by  several  physicians  at  one  and  the 
same  watering  place,  is  very  varied ;  I  will  therefore,  in  view  of 
the  absence  of  any  standard  or  commonly  accepted  rule,  speak 
only  of  that  method  of  employing  the  mineral  waters  to  which 
I  adhere  on  the  ground  of  my  own  experience  extending  over 
many  years. 

The  quantity  of  the  daily  dose  of  the  waters  depends,  of 
course,  on  what  you  have  in  view  when  prescribing  the  water, 
and  consequently  on  the  character  of  the  water  chosen  for  the 
purpose.  Within  the  limits  of  the  effects  of  the  waters  selected 
by  us  for  comparison,  we  may  note  the  following  most  impor- 
tant objects,  that  we  most  frequently  strive  for  : 

1.  We  strive  to  secure  a  direct  effect  on  the  mucous  mem- 
brane of  the  stomach  and  the  upper  portion  of  the  intestines,  or, 
besides  this,  by  way  of  absorption  of  the  mineral  water  by  the 
intestine  and  by  its  entrance  into  the  blood,  on  the  mucous 
membrane  of  the  biliary,  urinary  and  resjDiratory  tracts,  on  bil- 
iary calculi  and  urmary  gravel ;  provided  the  intestmal  evacua- 
tions of  the  patient  take  place  regularly.  In  such  cases  we 
usually  prescribe  Ems,  Obersalzbrunnen,  Vichy  and  Yessen- 
tucki,  in  doses,  for  adults,  from  two  to  six  times  a  day  (the 
usual  dose  is  one-half  glass,  i.  e.  four  ounces,  or  three-fourths 
of  a  glass,  i.  e.  six  ounces,  but  then  only  four  glasses  a  day):  for 
weak  and  exhausted  persons  two  or  three  half-giassfuls  of  Ems 
or  Obersalzbrunnen ;  for  strong  persons  with  a  good  nutrition 
three  to  six  half-glassfuls  of  Vichy  or  Yessentucki.  In  case 
there  is  a  tendency  to  diarrhea  I  prescribe  a  smaller  number  of 
doses  and  the  warm  sprmg,  or  water  warmed  up  to  the  required 


—  112  — 

temperature.  If  I  find  an  already  existing  diarrhoea,  then  I  order 
only  Ems,  m  smaller  doses,  and  at  times,  at  the  beginning,  only 
half-doses,  one-fourth  of  a  glass,  or  two  ounces  of  the  water, 
still  more  warmed.  In  cases  with  a  tendency  to  constipation  I 
use  Yessentucki  springs  and  in  a  greater  number  of  doses.  If 
in  addition  to  an  inclination  to  costiveness  the  patient  be  ex- 
hausted, weak  and  suffering  with  pains,  that  serve  as  an 
indication  for  warm  water  (gastric  pains  and  liver  colic),  then 
I  prescribe  Ems,  warmed,  in  less  frequent  doses  (for  mstance 
three  or  four  half-glassfuls)  and  at  the  same  time  evacuatmg 
clysters.  I  will  add  here,  that  both  for  cases  to  which  I  allude 
now  and  for  those  of  which  I  shall. speak  later,  we  can  prescribe 
in  summer  generally  more  water  than  at  the  cold  season  of  the 
year ;  because  movement  in  the  free  air  assists  the  organism  in 
better  sustaming  the  mineral  waters ;  and  light  summer  dress 
makes  out-door  movement  certainly  easier,  than  the  heavy 
whiter  overcoat.  Besides,  the  use  especially  of  warm  water  is 
rather  risky  m  winter :  at  the  hours  of  di'inkuig  one  must  not 
go  out  of  doors,  but  must  walk  aromid  the  room.  In  ordering 
movement,  whether  out-of-doors  or  withm  the  room,  while  ^^'ater 
is  bemg  takmg,  you  will  clearly  see  from  what  I  said  just  now 
and  from  the  examples  alluded  to  above,  that  every  given  case 
must  be  mdividualized,  i.  e.  we  must  take  into  considerstion  the 
season  of  year,  the  weather,  the  quantity  of  the  ordered  ^^^ater, 
the  strength  of  the  j)atient  and  indeed  the  whole  coui'se  of 
treatment. 

2.  We  have  m  view  the  same  aims  as  m  the  first  cases,  but 
we  deal  with  patients  who  either  suffer  constantly  from  consti- 
pation, or  from  a  constipation  that  is  at  times  intermittent  with 
a  diarrh(pa,  and  in  whom  we  must  therefore  take  pains  to  secure 
a  regular  evacuation  of  the  bowels,  but  at  the  same  time  to  pre- 
vent severe  purging,  as  that  would  destroy  our  chief  object, 
namely,  the  absorption  of  the  mineral  water  and  its  passage  into 
the  circulation  for  further  effect.  In  such  cases  I  either  order 
Yessentucki  (as  I  do  for  cases  with  a  tendency  to  costiveness) 
and.  moreover,  in  larger  doses  (up  to  six  half-glassfuls),  at  times 
with  the  addition  of  a  bitter  water,  or,  if  in  case  of  severe  pams 
(of  gastric  origin  and  liver  colic)  there  is  also  required  a  warm 


—  113  — 

or  even  a  hot  water,  then  Karlsbad  —  ui  wmter  three  to  four 
half-glass fuls  (if  necessary  I  add  Karlsbad  salt),  in  summer  from 
four  to  six  doses  of  three-quarters  of  a  glass  each,  also  with  the 
addition  of  the  salt,  if  necessary.  As  referred  to  above  (vide 
Yessentucki),  Karlsbad  water  may  in  such  cases  be  often  replaced 
by  the  warmed  Yessentucki,  with  the  addition  of  some  bitter 
water. 

3.  Finally  we  aim  not  only  at  evacuating  the  bowels,  but  at 
inducing  a  more  or  less  considerable  looseness  of  the  same  for 
a  certain  period  of  time,  as,  for  instance,  for  several  weeks.  For 
such  cases  I  order  Marienbad  or  Kissingen  or  Yessentucki  (with 
the  addition  of  a  bitter  water),  three-quarters  of  a  glass  per  dose, 
from  three  to  six  doses  a  day,  in  accord  with  the  desired  and 
obtained  results,  and  usually  only  during  the  summer.  The  use 
of  such  a  quantity  of  water  in  winter  or  generally  at  a  cold  sea- 
son of  the  year  is  inconvenient  and  risky,  as  it  absolutely  re- 
quires considerable  movement  or  at  least  a  prolonged  stay  out- 
of-doors.  In  the  winter  and  at  the  cold  season  generally  we  can 
reach  the  desired  effect  for  such  cases,  even  if  somewhat  slower, 
by  ordering  simultaneously  with  Yessentucki  some  bitter  water, 
—  of  l3oth  together  some  four  half-glassfuls  per  day  —  adminis- 
tering more  of  the  one  or  of  tlie  other,  in  accord  with  the  de- 
sired and  the  obtained  effect. 

For  how  long  a  jperiod  is  the  prescribed  water  to  he  taken? 
(The  length  of  the  course  of  treatment.)  Certainly,  up  to  the 
time  the  desired  object  is  effected  ;  but  I  usually  do  not  continue 
treatment  with  mineral  waters  for  longer  than  six  weeks  at  a 
time.  If  they  are  prescribed  for  a  recent  catarrh  of  the  stomach 
and  intestines,  or  of  the  biliary,  urinary  and  respiratory  tracts, 
then  the  above  length  of  time,  or  even  a  shorter  period  of  five, 
four  or  three  weeks,  is  quite  sufficient ;  just  as  in  the  cases  in 
which  the  waters  are  ordered  as  constant  laxatives.  But  for 
cases  of  chronic  catarrh,  biliary  calculi,  renal  gravel  and  gout  a 
six  weeks'  course  proves  frequently  insufficient ;  but  this  not- 
withstanding I  often  interrupt  for  a  time  the  use  of  the  pre- 
scribed water  after  six  weeks  or  before — for  two  reasons:  1. 
A  longer,  unmterrupted  administration  of  mineral  waters  tends 
to  disturb  digestion   and  nutrition,  as  there  appear  dyspeptic 


—  114  — 

phenomena,  and  the  patients  grow  thin  and  pale.  2.  As  the  ef- 
fects of  the  water  last  for  some  time  after  its  employment  has 
been  discontinued,  we  give  an  opportunity  for  the  results  of  the 
treatment  to  show  themselves,  after  we  have  ceased  employmg 
the  water  after  a  period  of  six  weeks  ;  then,  guided  by  these  re- 
sults and  by  the  condition  of  the  patient's  digestion  and  nutri- 
tion, we  are  enabled  sooner  or  later  to  return  to  the  treatment 
by  waters. 

The  distribution  of  the  prescribed  quantity  of  the  water  over  the 
course  of  the  day  must  be  made  in  accord  with  the  aim  we  have 
in  view.  If  the  water  be  employed  for  its  action  on  the  mucous 
membrane  of  the  stomach  and  of  the  intestines  and  also  for  its 
absorption  and  passage  into  the  circulation  and  for  further  action, 
then  we  must  assign  the  ordered  quantity  over  the  whole  day  — 
for  instance,  before  morning  coffee  or  tea,  midday  lunch  and 
dinner  (at  about  6  p.  m.  ;  it  is  better  to  avoid  the  use  of  the 
waters  late  at  night,  as  that  may  disturb  the  sleep).  But  if  the 
water  be  taken  for  its  laxative  effect,  then  all  the  prescribed 
doses  must  be  taken,  in  intervals  between  fifteen  and  twenty 
minutes,  in  the  morning  on  an  empty  stomach ;  this  is  quite  con- 
venient as  it  requires  at  the  same  time  movement  during  the 
summer  and  in  vigorous  persons  of  strong  constitution  and  fair 
strength ;  for  contrary  cases  we  must  order  one-half  of  the  doses 
before  the  morning  tea  and  coffee,  and  the  other  half  before  the 
midday  meal. 

A  mineral  water  is  always  to  be  taken  on  an  empty  stomach 
(the  last  dose  at  least  one  hour  prior  to  a  meal),  because  its 
action  on  the  mucous  membrane  of  the  stomach  and  intestines, 
as  well  as  its  absorption  and  its  laxative  effect,  have  then  a 
much  more  favorable  influence,  not  being  hindered  by  the  con- 
tents of  the  stomach  and  intestines.  A  mineral  .water  taken 
soon  after  a  meal  will  have,  if  an  alkalme,  only  a  palliative 
effect  on  the  dyspeptic  symptoms.  It  will  diminish  pyrosis, 
alleviate  belching  and  the  feeling  of  heaviness  m  the  stomach, 
but,  as  I  said  once  already,  will  with  difficulty  exert  its  princi- 
pal, most  important  action,  m  fact  may  completely  lose  it.  The 
practice  of  some  of  administering  the  mineral  waters  with  the 
meals,  —  usually  Vichy  or  some  other  alkalme  water  for  renal 


—  115  — 

gravel  and  gout  —  deserves  positive  condemnation.  Notwith- 
standing its  constant  administration,  the  gout  and  the  attacks  of 
renal  colic  are  not  influenced  at  all,  while  the  patient's  nutrition 
and  digestion  suffer  from  the  constant  introduction  of  a  mmeral 
water ;  besides,  the  use  of  the  mmeral  waters  in  the  ordinary 
regular  manner,  as  during  a  course  of  treatment,  does  not  bear 
as  good  results  in  these  patients,  as  it  does  m  patients  not  habit- 
uated to  the  constant  use  of  waters.  The  employment  of  alkaline 
mmeral  waters  m  cases  of  gout  and  renal  gravel  for  a  continu- 
ous period  of  time,  but  with  interruptions,  in  a  small  daily 
quantity  and  m  the  usual  manner,  i.  e.  on  an  empty  stomach, 
deserves  undoubted  preference  over  the  above-mentioned 
practice  of  constant  drinking  of  waters  during  meals.  The 
quite  extensive  employment  at  the  present  time  of  the  alkaline 
mineral  waters,  natural  and  artificial,  as  a  constant  beverage,  is 
prejudicial  on  the  same  ground. 

From  a  great  deal  of  what  I  said  concerning  the  mternal  use 
of  mmeral  waters,  it  is  easy  for  you  to  comprehend,  where  the 
cold  water  is  indicated  and  where  the  warm  one.  We  must 
now  give  more  precisely  the  temperature  of  the  prescribed  waters. 
Under  a  cold  water  we  mean  water  of  such  a  temperature  as 
can  be  Ixjrne  comfortably  by  the  stomach,  usually  not  below  the 
temperature  of  an  ordinary  apartment  in  winter,  i.  e.,  about  14° 
R.  (64°#.).  Of  the  waters  we  discussed,.  Marienbad,  Franzens- 
bad,  Kissmgen  and  Yessentucki  are  given  at  such  a  temperature 
(sometimes  a  little  higher)  for  their  laxative  effect.  Alkaline 
waters,  indicated  for  their  action  on  the  mucous  membrane  of  the 
stomach  and  intestmes  and  for  aljsorption,  are  admmistered  to 
persons  mclmed  to  constipation,  at  a  temperature  of  about  18^  to 
20°'i?.  (74°  to  78°jP.),  and  to  those  with  a  tendency  to  diarrhfjea 
at  the  temperature  of  freshly  drawn  milk,  i.  e.  about  25°  to  2.1° IL 
(88.2°  to  92.T°i^.),  while  for  diarrhcea  with  severe  gastric  and 
intestinal  pains  as  well  as  for  kidney  gravel,  they  are  given 
warmer  still. 

While  drinld]ig  the  mmeral  waters  such  a  diet  is  ordered 
as  is,  firstly,  required  by  the  condition  of  the  patient;  and  sec- 
ondly, all  the  very  sour  articles  of  food  are  to  be  excluded,  as 
the  use  of  vmegar  with  meals,  lemon,  also  cucumbers,  mush- 


—   116  — 

rooms,  berries  and  fruits,  so  as  to  avoid  a  possible  diarrhcea,  fre- 
quently of  a  severe  nature,  accompanied  by  acute  intestinal 
pains,  and  so  obstinate,  as  to  require  not  only  an  interruption  in 
the  treatment,  but  a  prolonged  cessation  of  the  same,  because  a 
return  to  the  use  of  the  mineral  water  brings  on  a  recurrence  of 
the  diarrhoea.  Ripe,  sweet  berries  are  sometimes  borne  well 
while  the  mmeral  waters  are  employed,  but  this  is  always  risky, 
as  together  with  the  sweet  ones  there  may  be  some  that  are 
unripe  and  sour. 

The  mineral  waters,  used  as  they  are  at  the  present  time  in 
smaller  and  moderate,  as  compared  with  the  past,  quantities,  are 
contraiyidicated  only  in  considerable  disturbances  of  the  circu- 
lation, h(jematopoiesis  and  nutrition,  in  conditions  of  cachexia 
and  marasmus.  —  We  have  often  seen  anaemic  and  exhausted 
persons,  as,  for  instance,  our  patient,  or,  still  more  frequently, 
women  exhausted  by  pregnancies  and  diseases  of  the  sexual  ap- 
paratus, but  with  an  undoubted  gastric  catarrh,  for  whom,  in 
view  of  their  ansemia  and  exhaustion,  one  rather  hesitates  to 
order  a  mineral  water,  hoping  to  cure  them  by  directly  ordering 
forced  alimentation,  iron  and  arsenic,  but  without  first  improvmg 
the  condition  of  the  stomach.  Such  attempts  —  I  repeat  again, 
m  the  presence  of  an  undoubted  gastric  catarrh  —  always  fail : 
the  "  nutritious  "  food  does  not  nourish  the  patient,  as  it  is  not 
digested ;  on  the  contrary,  introduced  in  large  quantities  (at  the 
advice  of  the  physician  —  the  so-called  forced  alimentation)  and 
in  conjunction  with  iron  and  arsenic,  it  tends  to  derange  diges- 
tion still  more  and  through  that  the  general  condition.  On  the 
contrary,  —  by  regulating  strictly  the  hygiene,  and,  particularly, 
the  diet  and  physical  exercise  (i.  e.,  prohibiting  any  fatigue),  and 
by  ordering  general  massage,  it  becomes  possible,  even  in  such 
cases,  by  the  moderate  use  of  the  light  mineral  waters  and 
bitter  drugs,  to  so  improve  the  condition  of  the  patient's  stomach-, 
as  to  make  it  possible  to  further  improve  the  general  condition 
and,  consequently,  that  of  the  stomach  itself.  Our  patient  may 
serve  as  a  good  example  of  the  results  of  such  a  mode  of  treat- 
ment. 

Nervous  dyspepsia  certainly  does  not  present  any  contra- 
indication for  the  use  of  mineral  waters,  if  it  be  accompanied  by 


—   117  — 

certain  morbid  conditions  presenting  an  indication  for  their  use, 
as,  for  instance,  gastric  catarrh,  renal  gravel,  gout,  etc. ;  in  the 
absence  of  such  indications  it  would  be  erroneous  to  rely  on 
the  mineral  water  alone  as  a  cure  for  nervous  dyspepsia.  Of 
the  treatment  of  this  so  frequent  and  so  important  morbid  con- 
dition we  shall  speak  when  discussing  cases  of  patients  subject 
to  it. 

Condition  of  patient  October  18th,  1889.  Patient  is  given  the 
same  food.  His  condition  is  as  good  as  it  was  five  days  ago,  when 
we  saw  him  last.  During  these  five  days  he  gained  one  pound 
in  weight,  —  he  weighs  now  ninety-nine  pounds,  eight  pounds 
more  than  he  weighed  on  admission.  Of  the  morbid  symptoms 
there  remain,  although  constantly  dimmishing,  the  former  pains 
in  the  left  kidney  on  motion,  leanness  and  physical  weakness. 

What  is  to  be  done  further?  Having  finished  the  analysis 
of  the  present  case,  and  the  plan  of  treating  it,  and  having 
brought  the  patient  to  a  very  satisfactory  condition,  we  must 
proceed  to  the  analysis  of  other  patients ;  it  will  thus  be 
impossible  for  us  to  return  to  him  as  frequently  as  heretofore, 
and  it  is  therefore  necessary  to  outline  the  plan  of  future 
treatment  for  a  longer  time,  which  is  at  jDresent,  after  our  treat- 
ment has  been  justified  by  the  obtained  results,  certainly  more 
possible  than  it  was  at  the  beginning. 

The  patient  has  been  taking  the  Ems-Kesselbrimnen  for  the 
last  five  weeks ;  notwithstanding  the  complete  absence  of  dys- 
peptic phenomena,  still  caution  requires,  that  we  do  not  dis- 
contmue  at  once  the  use  of  this  water,  but  continue  it  for 
another  week.  First,  because  the  patient  has  had  the  catarrh 
for  such  a  long  time ;  secondly,  the  dyspeptic  phenomena  are 
absent  when  very  light  food  is  taken  with  due  care  (little  at  a 
time  and  frequently),  whereas  the  patient  has  to  return  to  his 
habitual  rougher  food ;  and,  thirdly,  to  meet  as  much  as  possible 
the  renal  indications  (oxalic  acid  gravel). 

We  will  also  continue  for  another  week  the  drops  of  coto, 
dimmishing  the  dose  contmually  for  the  same  reasons,  —  so  as 
to  secure  the  obtained  result,  the  cessation  of  the  diarrhoea. 

The  bitters  (condurango  and  tinctura  nucis  vomicae)  we  will 
continue  for  a  long  period,  very  likely  up  to  the  time  he  leaves 


—  118  — 

our  clinic,  as  experience  has  shown  the  utility  of  their  prolonged 
administration  after  an  obstinate  catarrh  of  the  stomach  and  in- 
testines of  such  duration,  especially  in  emaciated  patients,  and 
also  in  view  of  the  approaching  change  in  his  food. 

The  baths,  which  continue  to  influence  the  patient  favorably, 
will  be  ordered  for  him  only  at  rare  intervals,  in  view  of  the 
fact,  that  he  will  soon  begin  taking  out-door  walks  in  the  free 
air. 

We  will  continue  massage  up  to  the  time  when  the  pa- 
tient will  become  strong  enough  to  be  able  to  walk  and  to 
generally  move  around  in  a  measure  satisfactory  to  his  health. 
The  pains  in  the  region  of  the  left  kidney  depend,  as  was 
explamed  above,  partly  on  the  oxalic  acid  gravel  and  partly  on 
the  displacement  of  this  organ.  Instead  of  the  former  abdom- 
inal bandage  the  patient  put  on  yesterday  a  kidney  truss,  and 
to  judge  by  the  considerable  relief  thereafter  of  the  above-named 
pains  on  motion,  we  may  well  hope  to  remove  them  entirely. 

What  shall  we  do  to  further  improve  the  patient's  nutrition 
and  his  physical  vigor  ? 

We  cannot  thmk  of  resortmg  to  an}'  fattening-  means ;  the 
use  of  koumyss  at  this  season  of  the  year  and  under  hospital 
conditions  is  out  of  the  question.  It  were  besides  risky  to 
order  koumyss,  kephir  or  cod  liver  oil  on  account  of  the  only 
recently  passed  dyspeptic  phenomena  and  the  diarrhoea  that 
ceased  not  long  ago.  We  must  then  confine  ourselves  to 
the  correct  regulation  of  the  food. 

For  the  same  reasons  it  would  be  risky  to  give  arsenic  and, 
although  not  to  such  an  extent,  also  iron.  But  then,  our 
patient's  appetite  is  so  good,  and  his  weight  increases  so  consid- 
erably, that  there  appears  to  be  no  necessity  for  resorting  to 
these  drugs. 

After  he  will  have  discontinued  the  use  of  the  Ems  water, 
we  will  think  of  prescribing  for  him  silver  nitrate,  m  view  of  the 
considerable  weakness  of  the  patient's  nervo-muscular  apparatus, 
and  also  in  view  of  the  recently  ceased  intestinal  catarrh,  so  that 
we  may  the  better  secure  the  now  present  good  condition  of  the 
intestinal  tract.  Until  now  we  have  not  yet  ordered  any  out- 
door walks  for  our  patient,  although,  considering  his  prei-  ent 


—  119  — 

condition,  lie  could  take  these  to  some  extent,  and  they  would 
certainly  benefit  him ;  but  we  did  not  allow  them  on  account  of 
the  extremely  unfavorable  weather  —  it  being  damp,  windy  and 
cold.  It  would  be  beneficial  for  the  patient  to  spend  the  winter 
in  the  South,  in  a  warm  climate,  where  he  would  be  able  to  stay 
out-of-doors  for  a  long  time  and  move  around  clad  in  a  light 
garment,  convenient  for  a  weak  patient :  this  would  tend  to  rap- 
idly improve  his  nutrition  and  strength,  and  through  these  also 
his  constitution  (growth).  It  certainly  would  be  cruel  irony,  in 
view  of  the  patient's  poor  or  even  wretched  circumstances,  to- 
recommend  him  a  trip  to  the  South  ;  but  my  duty,  as  that  of  a 
clinical  instructor,  requires  that  I  point  out  to  you  the  indica- 
tions for  climatic  therapy,  that  you  may  take  advantage  of  them 
in  treating  other  patients. 


FROM  THE  LECTURE  OF  NOVEMBER  28,   1889. 

Almost  six  weeks  have  passed  since  we  saw  the  patient  last. 
He  continued  taking  after  that,  for  a  whole  week,  the  Ems  water 
and  the  coto  drops,  and  then  left  them  off.  Five  weeks  have 
passed  since,  and  his  digestion  remains  good,  notwithstanding  the 
fact  that  his  food  is  coarser  now.  He  continues  the  use  of  the 
bitters.  In  accord  with  our  propositions  he  was  given  three 
weeks  ago  pills  of  silver  nitrate,  of  one-twentieth  grain  per  dose 
(with  extr.  trifolii),  at  first  three  times  a  day,  the  last  ten  days 
four  times  a  day,  every  time  immediately  before  a  meal.  We 
discontmued  the  baths  recently,  and  instead  of  these  he  is 
sponged  twice  a  week,  m  the  morning,  with  a  mixture  of  brandy 
and  water,  half  and  half,  at  first  of  the  temperature  of  fresh 
milk  and  later  somewhat  cooler,  followed  by  rubbmg  with 
flannel ;  this  he  bears  well,  does  not  feel  chilly,  but  feels  hale 
and  hearty.  Massage  is  continued  less  frequently  than  before, 
as  the  patient  walks  around  a  great  deal.  Three  days  ago 
(November  25th),  m  a  light  frost  and  during  pleasant,  dry 
and  quiet  weather,  the  patient  began  his  fresh-air  walks,  at  first 
twice  a  day,  half  an  hour  each  time  —  and  this  seemed  to  do  him 
good :    he  is  not  chilly,  does  not  become  fatigued  and  sleeps 


—  120  — 

better  after  it.  Some  three  weeks  previous  to  these  walks,  which 
could  not  be  taken  on  account  of  the  uninterruptedly  bad 
weather,  the  patient,  being  confined  in  the  room  and  deprived  of 
fresh  air,  began  to  sleep  poorly,  but  he  was  improved  by  frank- 
linization (static  electricity),  which  was  resorted  to  rather  than 
the  use  of  hypnotics  internally. 

Patient's  condition  at  presetit.  He  gets  rougher  food:  more 
than  a  pound  of  bread  —  half  of  white  bread,  the  other  half 
pound  of  rye-bread;  instead  of  chicken  and  beef  cutlets  —  a 
pound  of  beef ;  instead  of  chicken  soup  —  lately,  cabbage-soup, 
besides  —  six  eggs,  three  glasses  of  milk  with  cognac,  two  spoon- 
fuls of  wine.  Digestion  entirely  normal.  With  the  kidney  truss 
on,  pains  in  the  left  kidney  are  experienced  only  when  maldng 
very  abrupt  movements,  and  even  then  they  are  slight,  while  in 
ordinary  walking,  and  especially  when  at  rest,  none  at  all  are 
experienced.  Examination  of  the  abdomen  elicits  but  slight 
sensitiveness  in  the  region  of  the  left  kidney.  Pulse  of  normal 
strength.  The  patient  has  grown  considerably  m  body  (his 
weight  now  is  111  pounds,  or  20  pounds  more  than  what  he 
weighed  on  admission)  and  loolcs  hale ;  there  appeared  even  a 
slight  flush  on  his  cheeks.  His  sleep  is  good,  mental  condition 
splendid  and  physical  strength  very  much  improved.  " 

The  patient,  or  rather  the  convalescent,  desires  to  leave  our 
clinic  in  about  two  weeks,  before  Christmas,  so  as  to  visit  his 
parents.  Up  to  that  time  he  will  continue  the  bitters,  the  silver 
nitrate  pills  and  the  sponging,  and  also,  at  intervals,  franldiniz- 
ation  and  massage,  till  the  gradually  mcreasing  walks  will  per- 
mit us  to  dispense  with  them.  We  will  also  continue  to  gradu- 
ally introduce  our  patient  to  food  that  approaches  Ms  habitual 
one. 


Patient  left  the  clinic  December  15th,  strong  and  havmg 
become  stout  (his  weight  115  pounds —  24  pounds  more  than 
he  weighed  on  admission),  and  digesting  freely,  for  the  last 
week,  cabbage-soup,  buckwheat-gruel  and  rye-bread.  On  his 
departure  he  was  advised  not  to  eat  much  at  a  time,  to  avoid 
fatigue,  and  not  to  go   to   any  bathing  establishment  in  bad 


—  121 


weather,    but   to    sponge    himself   mstead    with  a   mixture    of 
water  and   brandy. 


Our  clmical  assistant,  Dr.  Nikulin,  received  two  letters  from 
the  former  patient,  one  in  the  middle  of  February,  and  the 
other  mthe  middle  of  April,  1890.  He  writes  in  the  firft 
that  he  IS  well  and  bears  the  wmtry  weather  well  fdoes  not 
catch  cold),  and  also  the  ordmary  peasant's  food,  and  in  the 
second,  that  at  the  time  of  the  great  fast  days  (before  Easter) 
he  a  e  well  and  has  borne  well  the  fast  meal,  has  not  experi- 
enced with  this  any  abdominal  pains,  has  neither  grown  thin 
nor  weak.  ^ 


SECOND  CASE 


LECTURES  OF  OCTOBER  20  AND  24,  1889. 

The  patient  before  you  has  been  in  the  cluiic  for  three  weeks 
already.  The  detailed  analysis  of  the  first  patient  I  presented 
to  you  terminated  only  with  the  last  lectm-e,  preventing  me  until 
now  from  presenting  before  you  this  one.  Meanwhile  the  con- 
dition of  this  patient  has  undergone  a  considerable  change  for 
the  better ;  but  the  case  is  so  mstructive  that  I  consider  it 
necessary  to  acquaint  you  with  it. 

The  patient  is  fort}''  years  of  age,  was  admitted  to  the  clinic 
September  29th,  complaming  of  constant  heaviness  and  pain 
in  the  stomach,  aggravated  by  meals,  of  belching  of  gas  of 
the  odor  of  rotten  eggs,  of  pyrosis,  nausea  and  vomiting  of 
large  masses. 

Conditions  and  mode  of  living.  Patient  spends  about  three 
summer  months  in  the  country,  the  rest  of  the  year  he  lives  in 
the  city;  in  either  of  the  places  in  a  healthy  locality  and  a 
good  house.  Is  not  habituated  to  open  air  bathing  (sea  or 
river),  but  takes  his  bath  in  the  public  bath-house  once  a 
month.  Smokes  a  great  deal  (about  forty  cigarettes  per  day), 
does  not  drink  any  brandy,  and  but  little  and  seldom  wine 
and  beer.  Used  to  drink  formerly  a  little  very  sweet  tea, 
but  discontinued  it  lately  on  account  of  the  pjTOsis,  and  drinks 
only  water,  four  glasses  a  day.  Has  three  meals  daily ;  is  fond 
of  fat,  sweet  and  cold  articles  of  food  (as  ice-cream),  dislikes 
meat,  nor  can  he,  as  he  says,  bear  it.  Patient  Ls  married,  denies 
ever  having  been  affected  with  syphilis,  and  presents,  neither 
from  the  investigation  of  his  present  condition  nor  from  his 
past  history,  no  indication  of  the  latter.  Patient  is  occupied 
durmg  the  summer,  in  the  capacity  of  a  manager  of  a  country 
place,  with  rural  economy ;  has  much  to  do,  and  is  subjected  to 


—  123  — 

a  great  deal  of  worry;  never  sleeps  enough,  is  constantly 
fatiguing  himself,  eats  irregularly  and  always  in  a  hurry ;  in 
winter,  the  other  extremes :  has  no  responsible  occupation, 
leads  a  secluded  life,  plays  cards,  reads,  moves  very  little  in 
the  open  air  and  has  little  exercise. 

Anamnesis  until  his  admission  to  the  clmic  and  for  the  time 
he  has  been  there.  —  Patient  comes  from  a  healthy  family.  Does 
not  remember  having  had  any  sickness  until  his  fifteenth  year  ; 
in  his  sixteenth  year  he  had  some  febrile  affection ;  in  his 
twenty-first  had  passed  through  an  attack  of  typhoid  fever. 
Since  his  twenty-fifth  year  he  began  his  activity  as  a  country 
manager,  leading  the  above-described  mode  of  life.  It  is  to  this 
period,  that  he  refers  the  beginning  of  his  present  illness,  the 
appearance  of  heaviness  (but  no  pains)  in  the  stomach,  of  belch- 
ing, heartburn,  nausea  and,  very  seldom,  of  vomitmg.  Some 
three  years  later  these  phenomena  became  aggravated  and  to 
them  was  added  constipation.  Two  years  later,  that  is,  about 
ten  years  ago,  along  with  the  aggravation  of  the  above-named 
symptoms,  there  appeared  severe  pams  in  the  stomach,  and 
vomiting  of  dark,  ground-coffee  like  masses.  Patient  began 
to  take  Yessentucki  water  and  improved  considerably;  but  the 
morbid  symptoms  again  became  worse  in  the  course  of  a  year. 
Patient  drank  Karlsbad  water,  was  treated  with  silver  nitrate, 
and  another  period  of  improvement,  lasting  one  and  a  half  years, 
followed;  but  returning  to  his  former  mode  of  living,  the 
morbid  condition  became  agam  aggravated,  and  since  then 
until  the  present  time  there  took  place  no  considerable  im- 
provement of  even  a  temporary  nature,  but,  on  the  contrary, 
the  condition  grew  steadily  worse.  Patient  began  to  grow 
thin  and  weak,  slept  badly,  became  low-spirited  and  irritable. 
He  always  felt  better  durmg  summer  than  in  winter,  thanks 
to  the  constant  outdoor  occupation  and  notwithstanding  the 
irregularity  of  his  life.  Since  his  treatment  with  Karlsbad 
water,  or  since  more  than  seven  years  ago,  the  patient  has 
not  been  treated  any  more  with  mineral  waters,  but  has  been 
takhig  various  pharmaceutical  preparations,  without  deriving 
any  substantial  benefit  therefrom.  ISTor  was  he  treated  by 
gastric  lavage.     For  the  last  six  weeks  the  morbid  symptoms 


—  124  — 

have  become  especially  aggravated:  the  pains  m  the  stomach 
became  excruciating ;  to  obtain  a  relief  from  them,  the  patient 
at  times  caused  vomiting  intentionally  ;  besides,  spontaneous 
vomiting  of  large,  coffee-like  masses  took  place  once  in  ten  days  ; 
the  vomited  matter  usually  contained  particles  of  food,  more 
frequently  of  meat,  ingested  several  daj^s  previously. 

Directly  on  the  second  day  of  his  admission  the  patient's 
stomach  was  washed  out  with  Ems  water;  this  brought  away 
an  enormous  quantit}'  of  mucus  — through  the  sound  and 
along  its  sides.  The  washing  was  repeated  on  the  next  day, 
but  m  view  of  the  great  quantity  of  mucus  the  Ems  water 
was  replaced  by  a  stronger  (two  per  cent)  solution  of  sodium 
bicarbonate,  so  as  to  more  certamly  clear  the  mucous  mem- 
brane of  the  stomach  of  the  accumulated  mucus.  This 
second  washing  also  brought  away  a  great  quantity  of  mu- 
cus. After  the  washings  the  pams  and  heavmess  were  con- 
siderably relieved.  He  was  given  internally  Ems-Kesselbrun- 
nen  at  the  temperature  of  freshly  drawn  milk,  a  half  glass- 
ful three  times  a  day,  each  time  one  hour  before  the  meal ; 
five  drops  of  tinct.  of  nux  vom.  twice  a  day,  after  each  meal 
(the  decoction  of  condurango,  prescribed  at  the  beginning,  was 
set  aside,  as  it  tended  to  increase  the  pyrosis) ;  for  severe 
pyrosis  magnesia  usta,  about  one-fourth  of  a  teaspoonful  for 
a  dose ;  for  the  relief  of  the  severe  abdoinuial  pams  we  tried 
first  bismuth  subnitrate  (in  5  gr,  doses)  and  tinctura  canna- 
bis indicee  (in  doses  of  10  drops),  but  they  were  of  little  avail, 
and  we  replaced  them  successfully  with  one-fourth  gr.  doses 
of  codeine  (+5  gr.  of  carbonate  of  sodium).  For  constipation 
a  clyster  of  two  to  three  glasses  of  water  at  the  temperature 
of  warm  milk,  every  other  day.  In  view  of  his  wealaiess  and 
the  exacerbation  of  the  pains  on  motion,  the  patient  was  advised 
to  repose  (which  he  preferred  himself)  and  to  avoid  sudden 
changes  of  position.  The  abdomen  was  protected  by  a  flannel 
bandage.  A  preferably  liquid  food  was  ordered  —  neither  cold, 
nor  hot,  at  the  temperature  of  warm  milk,  of  a  bland  charac- 
ter and  in  small  quantities  at  a  time.  At  first  the  patient  was 
given,  for  a  whole  day,  only  two  glasses  of  chicken  bouillon, 
one  glass  of  milk,  about  one-half  a  glass  of  milk-manna  gruel. 


—  125  — 

two  eggs  and  about  one-fourth  pound  of  white  bread,  ^Yithout 
the  crust.  The  quantity  of  food  was  increased  proportionately 
with  the  improvement  in  the  patient's  condition. 

Strong  Crimea  wine,  which  the  patient  drank  rather  reluctant- 
ly, but  which  had  to  be  given  on  account  of  some  weakness  of 
the  pulse,  was  administered  in  tablespoon  doses  once  or  twice  a 
day ;  to  the  milk  was  added  some  cognac,  a  teaspoonful  to  a 
glass  of  milk.  All  these  included  his  food  and  drink  the  fhst 
time.     He  was  advised  to  smoke  as  little  as  possible. 

During  the  early  time  of  his  residence  in  the  clinic,  the  pa- 
tient had  two  attacks  of  vomiting,  but  of  less  abundant  contents 
than  formerly.  Examination  proved  the  vomited  matter  to  con- 
tain leucocytes,  sarcina  ventriculi,  heematin  and  free  HCl.  the 
latter  in  a  quantity  even  greater  than  normal  (three  and  one- 
half  in  one  thousand),  while  a  specimen  portion  of  fibrin  was 
completely  and  rapidly  digested.  Another  washing  of  the  stom- 
ach after  the  second  vomiting,  with  a  two  per  cent  solution  of 
bicarbonate  of  soda,  brought  away  much  less  mucus  than  the 
first  two  washings.  Xotwithstanding  the  fact,  that  he  felt  very 
much  relieved  after  each  washing,  which  apparently  exerted  a 
favorable  miiuence  on  the  course  of  the  disease,  the  patient  sub- 
jected himself  to  them  rather  reluctantly  ;  iDut  after  the  thiid 
washing  the  disease  took  such  a  favorable  course,  that  there 
appeared  no  necessity  to  insist  on  further  washings,  and  we  are 
satisfied  with  the  above  outlined  treatment. 

The  present  condition  of  the  patient  is,  as  I  said  before,  much 
better  than  it  was  on  his  admission.  The  appetite  is  keener. 
The  first  days  the  patient  was  given  for  a  whole  day  two 
glasses  of  chicken  bouillon,  a  glass  of  milk  with  cognac,  about 
one-half  glass  of  milk  soup  with  manna,  two  eggs,  and  about 
one-fourth  pound  of  white  bread ;  he  gets  now  one-half  pound 
of  white  bread,  four  eggs,  two  glasses  of  milk  soup  with  manna, 
two  glasses  of  bouillon  with  manna  semolino  and  four-  glasses  of 
milk  with  cognac  (outside  of  this  no  beverage  but  one  and  one- 
half  glasses  of  Ems  water)  and,  as  you  will  hear  presently,  he 
is  able  to  digest  all  this  food  much  easier  than  before.  He  gets 
his  wine,  as  heretofore,  one  or  two  spoonfuls  per  day.  As  he 
takes  meat  rather  reluctantly  and  observes  after  its  ingestion  an 


—  126  — 

aggravation  of  the  gastric  symptoms,  we  do  not  insist  upon  his 
eating  it.  The  gastric  symptoms  may  at  the  present  time  be 
summed  up  as  follows:,  at  about  five  P.  M.  the  patient  experi- 
ences pains  at  the  pit  of  the  stomach,  (he  takes  his  dinner  at  one 
P.  M.  and  drinks  a  glass  of  milk  at  about  three  P.  jM.),  which  are 
quite  bearable  while  he  is  resting,  but  increase  on  his  moving 
about,  and  which  are  relieved  by  an  easy  belching  of  odorless 
gases  ;  they  disappear  at  seven  p.  M.,  when  food  is  taken  again. 
During  the  rest  of  the  day  the  patient  is  almost  free  from  any 
gastric  symptoms ;  whereas  on  his  admission  he  ahiiost  continu- 
ously suffered  from  painful  belching  of  fetid  gas  and  sour  liquid, 
conjoined  with  a  feeling  of  very  severe  heartburn,  nausea,  and 
acute,  at  times  even  excruciating,  pains  in  the  upper  part  of  the 
abdomen  simultaneously  with  pain  in  the  opposite  part  of  the 
back.  The  improvement  of  the  patient  is  also  evident  from 
the  fact,  that  for  the  last  ten  days  there  appeared  no  necessity 
for  resorting  to  the  above-mentioned  palliative  means  against 
pyrosis  and  the  pains.  There  was  no  vomiting  for  about  two 
weeks.  The  obstipation  also  begms  to  disappear :  there  were 
normal  movements  for  the  last  three  days  without  the  aid  of 
clysters.  The  urine  is  somewhat  pale,  but,  outside  of  this, 
normal.  The  organs  of  both  respiration  and  circulation  present 
nothing  abnormal :  pulse  60  to  70,  was  somewhat  weak  on  ad- 
mission, but  is  of  almost  normal  strength  now.  The  patient, 
who  never  was  fat,  naturally  became  yerj  thin  while  ailing. 
The  temperature  is  below  normal,  about  36°  (about  98°^.) 
seldom  a  little  higher.  The  sleep  is  short,  about  six  to  seven 
hours,  but  much  more  sound,  than  it  was  on  his  admission, 
when  it  was  disturbed  by  abdominal  pains.  Mental  condition 
now  better.  Dizziness  and  the  pains  at  the  nape  of  his  neck,  to 
which  he  was  subject  while  suffering  with  obstinate  constipation, 
do  not  trouble  him  any  more.  The  patient  is  stronger  than  he 
was  on  admission. 

The  objective  examination  of  the  abdomen  gives,  as  you  see,  the 
foUowmg  results.  Abdomen  not  distended,  whereas  on  his 
admission  there  was  considerable  bulging  of  the  upper  part  of  the 
abdomen,  and  especially  so  in  its  median  portion  and  left  half. 
There  is  no  cutaneous  hyperEesthesia,     Tenderness  on  pressure 


—  127  — 

along  the  median  line,  from  the  xyphoid  cartilage  to  the  umbili- 
cus, is  more  noticeable  in  the  direction  upwards ;  below  the 
umbilicus  along  the  same  line  there  is  no  tenderness.  Both 
hypochondrial  regions,  especially  the  left  one,  are  tender  on 
pressure :  the  right  at  a  point  that  corresponds  more  to  the 
position  of  the  pylorus  than  to  the  gall-bladder.  There  is  sensi- 
tiveness on  pressure  in  the  region  of  the  caecum  and  the  ascend- 
ing portion  of  the  colon.  No  other  abdominal  morbid  condi- 
tion is  elicited  by  the  objective  exammation. 

'  Diagnosis  *  It  is  evidently  the  stomach  that  is  chiefly  ai3^ected 
in  our  patient,  and,  besides,  not  by  one,  but  by  several  morbid 
conditions.  The  great  accumulations  of  mucus  and  the  presence 
of  leucocytes  in  the  gastric  contents  point  to  an  unquestionably 
severe  catarrh  of  the  stomach.  Vomiting  of  dark  liquid,  that 
accompanies  the  attack  of  acute  pains  over  the  whole  epigastric 
region,  and  especially  at  the  pit  of  the  stomach,  and  the  presence 
of  hcematin  in  the  above-named  liquid,  speak  in  the  present  case 
for  gastric  ulcer ;  we  shall  see  later,  why  cancer  is  excluded. 
We  also  observe  symptoms  of  nervous  dyspepsia ;  that  is,  a 
greater  or  weaker  development  of  the  dyspeptic  phenomena 
under  the  influence  of  a  respectively  better  or  worse  mental  con- 
dition, though  this  latter,  as  well  as  the  general  nervous  symp- 
toms (poor  sleep,  general  weakness)  depend  evidently  in  their 
turn  on  the  affection  of  the  stomach  and  the  pains  and  the  insom- 
nia resulting  therefrom :  from  the  anamnesis  and  from  observation 
of  the  patient  we  learn,  that  a  gloomy  and  irritable  mental  con- 
dition, insomnia  and  general  weakness  run  parallel  to  the  condi- 
tion of  the  gastric  symptoms,  and  that  they  mcrease  or  diminish 
in  proportion  as  these  are  better  or  worse.  Finally,  the  patient 
has  a  considerable  dilatation  of  the  stomach.  This  is  shown  by 
the  following :  the  very  marked  inflation  of  the  whole  epi- 
gastrium, especially  at  the  pit  of  the  stomach  and  m  the  left 
hypochondrium,  which  was  so  noticeable  before  the  washings, 
but  has  disappeared  since  ;  the  vomiting  of  great  masses,  that  has 
troubled  the  patient  for  such  a  long  time,  the  great  quantities  of 

*After  the  investigation  is  finished,  further  explanations,  regarding  diag- 
nosis, prognosis,  etc.,  are  always,  in  every  case,  conducted  in  the  patient's 
absence. 


—  128  — 

tlie  gastric  contents,  that  were  bronght  np  by  the  first  washing 
made  on  an  empty  stomacli ;  the  presence  in  these  masses,  as  ob- 
served by  the  patient  more  than  once,  of  food  mgested  several 
days  ago  ;  the  pamful  belching  of  great  quantities  of  fetid  gases 
and  sour  liquids,  which  pointed  to  stagnation  and  dj-speptic 
decomposition  of  the  gastric  contents.  On  patient's  moving 
about,  the  abdominal  splashing  was  also  clearly  heard.  I  men- 
tion this  sj'mptom  simply  because  it  was  present;  but  I  would 
certainly  not  attempt  to  cause  its  appearance  mtentionally : 
iirst,  because  it  would  be  inexcusable,  in  view  of  the  former 
attacks  of  acute  pams  and  the  great  sensitiveness  in  the  region 
of  the  stomach,  to  call  out  this  phenomenon,  as  there  would  be  a 
risk  of  simultaneously  causmg  the  appearance  of  such  an  attack; 
and  secondly,  because,  as  has  been  ex^Dlained  before,  I  do  not 
consider  this  phenomenon  as  a  reliable  symptom  of  dilatation  of 
the  stomach.  I  will  add  here,  that  I  know  of  cases,  where  the 
splash  was  caused  intentionalh^  and  where  the  somid,  mtroduced 
immediately  after  that,  showed  the  stomach  to  be  empty,  while 
after  the  sound  was  taken  out,  the  splashing  could  agam  be  pro- 
duced. In  view  of  the  above  midoubted  sj^mptoms  of  consider- 
able gastric  dilatation  it  would  be  a  profitless  task  to  resort,  for 
diagnostic  purposes,  to  such  doubtful  methods  of  investigation, 
as  the  mtroduction  into  the  stomach  of  gas-producing  mix- 
tures and  the  like ;  not  to  speak  of  inconveniencmg  the  patient 
or  even  of  subjectmg  him  to  dangers,  that  may  arise  from  such 
attempts.  As  regards  the  mtroduction  uito  the  stomach  of 
salol  and  the  consequent  determination  of  the  length  of  time, 
when  salyciluric  acid  could  be  detected  m  the  urine,  — the  appli- 
cation of  this  method  of  investigation  in  our  case,  in  the  pres- 
ence of  the  determmed  diagnosis  of  gastric  dilatation,  would  be 
but  a  "  scientific  '"  ornament  to  an  already  erected  structure ;  not 
to  mention  the  fact,  that  time  must  yet  prove  the  degree  of 
reliabilitj"  and  practicability  of  such  a  diagnostic  method.  I 
must  also  add,  that  not  only  does  our  patient  present  undoubted 
symptoms  of  considerable  gastric  dilatation,  but  that  the  absence 
of  such  a  morbid  condition  would  be  unmtelligible  in  his  case. 
Dilatation  of  the  stomach  may  appear  as  a  result  either  of  gas- 
tric catarrh  or  of  nervous  dyspepsia.     Our  patient  has  a  severe 


■     —  129  — 

gastric  catarrh  of  long  duration,  and  also  nervous  dyspepsia. 
The  symptoms  of  gastric  ulcer  in  the  given  case  have  also  been 
observed  for  a  long  time,  some  ten  years,  but  they  would  at 
times  disappear  for  a  year  or  a  year  and  a  half,  which  fact  would 
lead  us  to  think  of  former  cicatrization  of  the  ulcers  and  of 
present  scars.  However,  these  latter  seem  to  be  so  located, 
that  they  do  not,  at  least  not  to  a  great  extent,  embarrass  the 
egress  of  food :  we  are  led  to  think  thus  by  the  rapid  relief  from 
the  constipation,  which  indicates  a  sufficiently  free  passage  of 
the  gastric  contents  into  the  intestines. 

Does  not  the  patient  also  have  a  cancer  of  the  stomach? 
There  is  certainly  much  that  speaks  against  it :  the  sum  total  of 
the  gastric  symptoms  is  sufficiently  explained  by  the  undoubted- 
ly existing  affections,  namely :  by  the  catarrh,  the  ulcer  and  the 
gastric  dilatation,  and  also  by  the  nervous  dyspepsia ;  the  dura- 
tion of  the  illness,  the  absence  of  a  swelling  in  the  region  of  the 
stomach,  and  the  abundance  of  free  HCl  in  the  gastric  contents 
all  speak  against  cancer.  But  all  the  enumerated  data  make 
the  absence  of  a  gastric  cancer  in  this  case  only  very  probable, 
but  not  fully  certain :  there  is  also  in  gastric  cancer  observed 
sometimes  an  abundance  of  free  hydrochloric  acid  in  the  contents 
of  the  stomach ;  nor  is  it  rarely,  but  in  fact  frequently,  that  we 
are  unable  in  cases  of  cancer  to  detect  a  swelling  in  the  region 
of  the  stomach ;  it  is  not  at  all  impossible,  that  to  the  long  con- 
tinued gastric  suffermg  of  a  non-cancerous  character  in  our 
patient,  there  was  also  superadded  of  late  a  cancer  of  the  stom- 
ach. But  then,  such  apprehensions  could  only  be  entertained  on 
the  patient's  admission  to  the  clinic ;  at  present,  after  a  consider- 
able improvement  has  taken  place,  an  improvement  that  is 
generally  absent  in  cases  of  gastric  cancer,  and  would  be  so 
particularly  in  one  as  broken  down  as  our  patient  is, — at 
present  such  apprehensions  are  untenable. 

As  regards  the  other  organs  in  our  patient,  we  will  only 
note  the  tenderness  on  pressure  in  the  region  of  the  Ccecum  and 
the  ascending  portion  of  the  colon,  surely  dependmg  on  some 
slight  typhlitis  and  colitis,  as  results  of  the  prolonged  obstinate 
constipation.  The  liver,  spleen,  kidneys  and  the  urinary  blad- 
der,   as    well    as    the    organs    of    respiration    and    circulation. 


—  130  — 

present  nothing  abnormal.  We  have  already  alluded  to  the 
failure  of  nutrition  and  the  disturbances  of  the  nervous 
system. 

The  prognosis  is  certainly  more  favorable  now,  than  it 
was  on  the  patient's  admission  to  the  clinic,  when  we  appre- 
hended the  possibility  of  a  gastric  cancer.  But  even  now  his 
condition  must  be  considered  as  very  serious,  that  is,  as  one 
that  presents  no  immediate  danger,  but  a  great  possibility  of  the 
same,  thus  :  the  obstinate  gastric  ailment,  that  has  repeatedly 
reappeared  after  improvement  has  taken  place,  —  to  be  sure,  on 
account  of  the  patient's  negligence,  —  may  in  the  end  completely 
destroy  his  now  already  failing  health ;  some  accidental  cause 
may  bring  about  a  rupture  of  the  thinned-out  gastric  walls  at 
the  sites  of  the  ulcers  and  of  the  cicatrices.  We  have,  therefore, 
while  giving  him  hopes  of  a  return  to  health,  enjoined  upon  our 
patient  the  necessity  of  a  strictly  regular  mode  of  living  and 
circumspection  in  movements  and  exertions,  so  as  to  avoid 
dangerous  consequences. 

Treatmejit.  —  The  gastric  therapy  of  the  present  case  differs 
from  that  of  the  preceding  one,  chiefly  m  that  in  this  case  we 
ordered  lavage  of  the  stomach,  that  has  given  such  good  results. 
I  shall  discuss  this  important  method  of  treatment,  after  I  will 
have  explained  the  other  therapeutic  means ;  these  latter  will 
take  but  little  of  our  time  now,  after  our  discussion  of  the  first 
case.  It  is  certainly  not  necessary  for  me  to  explain  to  you 
why  the  patient  was  ordered  the  above-described  diet,  the  warm 
abdominal  bandage  and  rest,  and  why  he  was  given  a  mineral 
water  (I  shall  speak  later  of  my  reasons  for  prescribing  the 
Ems-Kesselbrunnen),  and  the  tincture  of  nux  vomica.  We 
have  explained  above  why  we  gave  codeine  and  magnesia  usta. 
We  did  not  order  any  warm  baths  for  the  relief  of  the  abdominal 
pains,  first,  because  the  codeine  relieved  the  pains  sufficiently, 
and  secondly,  that  he  might  avoid  movements  incident  to  un- 
dressing, immersing  in  the  bath  and  dressing  again ;  these,  as 
any  other  movements,  would  tend  to  aggravate  the  pains. 

Why  have  we  selected  of  all  the  mineral  waters  the  Ems- 
Kesselbrunnen  ?  Within  the  limits  of  the  waters  chosen  by  us 
for  comparison,  we  apparently  had  to  avoid  the  cold  springs  and 


—  131  — 

those  rich  in  carbonic  acid,  as  such  would  tend  to  aggravate  the 
gastric  pauis  and  the  vomiting  in  our  patient ;  and  we  also  had 
to  avoid  springs  rich  in  alkaline  and  laxative  salts,  because  of 
the  patient's  exhausted  condition.  For  these  reasons  we  had  to 
exclude,  first  of  all,  Marienbad,  Kissingen  and  Franzensbad,  they 
being  cold  springs,  and  to  select  from  among  Ems,  Karlsbad, 
Vichy  (the  warm  spring  of  Grande  Grille)  and  the  warmed 
Yeesentucki  springs.  In  view  of  the  patient's  debilitated  con- 
dition we  gave  the  preference  to  Ems,  as  it  does  not  contain  any 
laxative  salts  (like  Karlsbad)  and  is  less  rich  in  alkaline  salts, 
than  Vichy  and  Yessentucki ;  though  if  the  condition  of  the 
nutrition  were  better,  the  other  three  waters  could  be  given. 
And  as  a  matter  of  fact,  it  appears  from  the  anamnesis,  that  the 
patient,  when  in  a  better  condition  of  nutrition  and  strength, 
was  treated  with  success  by  the  Yessentucki  and  the  Karlsbad 
waters. 

All  this  refers  to  treatment  of  the  gastric  catarrh.  How  is 
ulcer  of  tjie  stomach  to  be  treated  ?  We  know  of  no  directly 
curative  remedy,  but  experience  teaches,  that  an  ulcer  heals 
under  the  same  treatment  and  the  same  (or  even  stricter  yet) 
diet,  that  is  so  successful  in  gastric  catarrh.* 

How  shall  we  treat  dilatation  of  the  stomach  ?  After  having 
removed  the  accumulated  gastric  contents  and  having  cured  the 
catarrh  and  the  ulcer,  it  would  be  necessary  to  attempt  to 
strengthen  the  nervo-muscular  apparatus  of  the  stomach  by  the 
aid  of  massage,  electricity  and  hydrotherapy  (douches  in  the 
region  of  the  stomach).  The  ulcers  and  cicatrices  of  long 
standing  in  the  present  case  would  make  it  very  risky  to  resort 
to  such  measures,  as  their  employment  would  bring  about  strong 
contractions  of  the  stomach,  and  consequently  a  liability,  not  to 

*  A  later  supplemental  note :  For  the  last  few  years  I  add  to  this  treat- 
ment the  use  of  bismuth  subnitrate  with  undoubtedly  successful  results. 
I  give  at  first  twenty-grain  doses,  increasing  the  dose,  later  on,  to  3  j  ss 
and  more,  once  or  twice  a  day,  — always  on  an  empty  stomach  (in  the 
morning  before  breakfast,  and  one  hour  before  dinner).  The  powder  of  bis- 
muth is  directly  put  on  the  tongue  and  is  washed  down  with  the  warm 
alkaline  water,  which  is  indicated  for  the  given  case.  The  patient  lies 
on  his  back,  then  turns  on  the  belly,  and  from  side  to  side,  so  as  to 
enable  the  remedy  to  more  certainly  come  in  direct  contact  with  the 
ulcer. 


—  132  — 

speak  of  the  pains,  of  rupturing  the  walls  in  the  thmned-out 
portion  of  this  organ.  However,  to  judge  by  the  favorable 
course  of  the  disease,  we  may  hope  that,  on  removing  the 
accumulated  gastric  contents  and  on  curing  the  catarrh,  the 
ulcer  and  the  nervous  dyspepsia,  the  strength  of  the  nervo- 
muscular  apparatus  of  the  stomach  will  reestablish  itself  to  a 
sufficient  extent; 

For  the  treatment  of  the  slight  typhlitis  and  colitis,  it  will  ua 
all  probability  be  sufficient  to  establish  a  regular  emptying  of 
the  bowels,  to  see  that  the  abdomen  is  kept  at  rest  and  warm, 
in  connection,  of  course,  with  the  contemporaneous  improvement 
in  the  gastric  ailment. 

The  improvement  in  the  nervous  disturbances  of  the  patient 
is  attained  as  yet  through  the  improvement  of  the  gastric 
trouble,  through  the  alleviation  of  the  pains  consequent 
upon  this  last  and  of  the  msomnia.  Later  on,  after  we 
will  have  finished  the  treatment  with  the  mineral  waters,  we  will 
think  of  combating  the  nervous  disturbances  and,  cojisequently, 
the  nervous  dyspepsia,  with  silver  nitrate,  which  the  patient  had 
used  before  with  great  success.  Arsenic  and  iron  are  contra- 
mdicated  by  the  condition  of  the  stomach.  We  will  besides 
order  for  our  patient  general  massage  (except  massage 
of  the  abdomen),  in  accord  with  the  indications,  which  we 
followed  in  our  first  analyzed  case.  We  hesitate  as  yet  to  order 
massage  under  the  apprehension,  that  the  movements  of  massage 
might  aggravate  the  abdommal  pams.  The  treatment  by  cold 
water,  with  a  view  of  improving  the  patient's  nervous  state,  is 
contra-indicated  by  his  exhausted  condition. 

I  will  now  take  up  the  subject  of  gastric  lavage.  The  pres- 
ent case  may  be  called  a  typical  example  of  the  class  of  cases, 
in  which  lavage  of  the  stomach  is  an  miconditional  indication  of 
such  importance,  that  without  its  previous  employment  no  other 
kind  of  treatment  can  be  instituted.  In  such  cases  even  one  or 
two  washmgs  are  sufficient  to  rapidly  brmg  about  important  re- 
sults :  by  carrjdng  away  a  mass  of  dyspeptically  decomposed 
gastric  contents,  absorption  of  the  products  of  such  a  decompo- 
sition —  certamly  very  injurious  to  the  patient  —  is  put  a  stop 
to,  as  well  as  the  irritating  effect  produced  by  them  on  the  walls 


_  133  — 

of  the  stomack,  causing  vomiting  and  pains  ;  consequently,  as  a 
result,  a  rapid  alleviation  of  the  symptoms  .is  effected ;  further,  the 
mucous  membrane  of  the  stomach  is  cleared  of  the  mucus,  and 
is  made  accessible  to  the  radical  treatment  of  the  catarrh  by 
mineral  waters  and  by  bitters  ;  finally,  the  nervo-muscular  appa- 
ratus of  the  dilated  or  distended  stomach  is  able,  on  the  latter 
being  emptied,  to  act  better,  namely  to  expedite  the  gastric  con- 
tents into  the  intestines  and  thus  prevent  a  fresh  accumulation. 
Therefore,  not  only  in  cases  of  such  a  prolonged  and  obstinate 
morbid  condition,  gastric  dilatation,  as  seen  in  our  patient,  but 
even  in  more  recent  cases  of  overloading  of  the  stomach,  in 
which  the  indications  for  emptying  this  last  are  as  positive  as 
they  are  in  our  present  case,  I  begin  the  treatment  with  gastric 
lavage,  repeating  it  several  times  till  the  patient  obtains  un- 
doubted relief  ;  and  at  the  same  time  I  begin  the  radical  treat- 
ment, if  possible,  of  the  gastric  disease,  most  frequently  of  the 
catarrh  or  of  the  nervous  dyspepsia,  that  has  caused  the  dilata- 
tion or  distention  of  the  stomach;  and  as  soon  as  the  acute 
symptoms,  the  attacks  of  pain,  and  vomiting,  and  pain  on  pres- 
sure in  the  region  of  the  stomach,  have  ceased,  I  add  to  the 
foregoing  such  remedial  means,  as  would  strengthen  the  weak- 
ened nervo-muscular  apparatus  of  the  stomach,  namely,  electri- 
city, massage,  or  douches,  according  to  the  idiosyncrasy  of  the 
case.  As  soon  as  the  sound  improvement  m  the  patient's  con- 
dition can  last  without  lavage,  I  at  once  discontinue  it ;  because 
experience  teaches  that  a  prolonged  employment  of  lavage  may 
generate  a  habit  for  it,  of  which  it  may  become  difficult  to  get 
rid ;  an  example  of  this  will  be  presented  later.  But  if  the  in- 
dications for  lavage  are  neither  so  positive,  nor  so  necessary, 
particularly  not  in  cases  of  old  dilatation,  hut  in.  those  of  recent 
distention,  then,  without  resorting  to  washings,  I  order  radical 
treatment  in  conjunction,  of  course,  with  regulation  of  the  hy- 
giene in  general  and  of  the  diet  in  particular. 

If  the  success  is  prompt  and  lastmg.  then  I  surely  content 
myself  with  the  adopted  treatment ;  otherwise  I  add  to  it  lav- 
age. Wherever  possible  I  avoid  lavage,  as  it  is  never,  especially 
at  the  beginning,  an  indifferent  process  and  far  from  beiag  harm- 
less for  the  patient,  not  to  speak  of  the  feeliag  of  disgust  enter- 
tained towards  it  by  him. 


—    134  — 

We  often  observe  in  practice,  how  lavage  —  which  was  for- 
merly and  is  to  an  extent  even  now  a  fashionable  procedure  —  is 
employed  quite  frequently  without  success.  Let  us  consider  the 
causes,  as  I  have  observed  them,  of  such  failures. 

The  most  frequent  cases  are  as  follows :  the  patient  suffers 
from  a  gastric  catarrh  in  a  condition  which  does  not  present  any 
indication  for  lavage.  At  first  the  physician  does  not  resort  to 
lavage,  and  orders  the  radical  treatment,  but  he  prescribes  it 
either  incorrectly  or  carelessly,  without  regulating  the  hygiene 
and  particularly  the  diet.  Failure  follows.  The  physician  now 
resorts  to  lavage,  without  having  correctly  instituted  his  former 
treatment  and  regulated  the  hygiene,  and  not  having  rectified 
his  former  errors  and  omissions,  failure  is  sure  to  come  again. 
—  Or  take  such  a  case.  The  patient  has  a  gastric  catarrh  in  a 
condition  presenting  positive  indications  for  lavage  :  this  is  or- 
dered by  the  physician,  but  he  neglects  the  radical  treatment  of 
the  catarrh,  forgetting  that  lavage,  though  an  excellent,  is  at  the 
same  time  but  a  symptomatic,  palliative  measure.  The  patient  is 
not  only  not  cured,  but  acquires  the  habit  of  washing  his  stom- 
ach, "  cannot  get  along  without  it,"  just  as  one  suffering  with 
constipation  and  habituated  to  clysters  is  unable  to  get  along 
without  these.  I  will  tell  you  in  this  connection  of  one  very 
instructive  case  from  my  practice.  The  patient,  thirty-five  years 
old,  of  good  constitution,  called  on  me  in  February,  1888,  com- 
plaining of  pain  and  heaviness  in  the  region  of  the  stomach, 
nausea,  poor  sleep  and  oppressed  mental  condition. 

Anamnesis.  —  Up  to  his  twenty-fifth  year  the  patient  enjoyed 
good  health ;  but  has  since  then  abused  alcoholic  drinks  (whis- 
key and  beer),  took  only  one  meal  a  day,  but  an  abundant  one, 
and  was  at  times  intensely  preoccupied  with  his  affairs  (he  is  a 
tradesman).  He  soon  grew  restless,  of  a  sad  mood,  and  costive. 
Some  five  years  ago  there  appeared  dyspeptic  gastric  symptoms 
and  pains  at  the  pit  of  the  stomach.  The  patient  continued 
drinking  and  leading  his  former  mode  of  life.  Two  years  ago 
the  gastric  pains  became  aggravated,  and  there  appeared  once  or 
twice  a  week  abundant  vomiting,  containing  considerable  quanti- 
ties of  mucus.  He  left  off  drinkmg  and  called  on  his  physicians  : 
these  ordered  daily  gastric  lavage  with  plain  water,  but  no  othei' 


—   135  — 

treatment,  cautioning  him  only  to  avoid  heavy  food.  The  first 
two  months  the  patient  experienced  considerable  relief,  but 
later  the  improvement  not  only  became  stationary,  but  gave 
way  to  a  more  aggravated  condition. 

Present  state.  — -  Patient  smokes  much  and  drinks  a  great  deal : 
nine  to  ten  glasses  of  tea  daily  with  cream,  and  four  to  five 
glasses  of  soda  or  artificial  seltzer  water ;  drinks  neither  beer, 
wine,  nor  brandy.  Washes  his  stomach  daily  for  the  last  year 
with  plain  water  on  an  empty  stomach;  this  brings  up  mucus, 
at  times  in  considerable  quantity.  The  lavage  procures  a  relief 
from  the  heaviness  and  pain  in  the  stomach,  from  the  nausea 
and  oppressed  mental  condition  for  one  or  one  and  one-half 
hours  (in  the  beginning  the  relief  lasted  one-half  day  or  even 
longer),  but  later  he  returns  to  his  usual  condition.  He  is  con- 
stipated :  movements  of  bowels  every  other  day  —  evacuations 
small  and  hard.  Once  or  twice  a  month  patient  takes  castor- 
oil  or  some  bitter  water.  Abdomen  distended.  The  liver, 
spleen,  kidneys  and  the  organs  of  circulation  and  respiration 
present  nothing  abnormal.  Nutrition  poor.  Sleep  unsatisfactory, 
mental  condition  oppressed.  Treatment :  Ems  water,  one-half 
glass  three  times  a  day,  one  hour  before  meals,  at  the  tempera- 
ture of  freshly  drawn  milk ;  decoction  of  condurango  and  the  tinc- 
ture of  nux  vomica  ;  watery  clysters  ;  once  during  the  day  fifteen 
grains  of  potassium  bromide  in  the  last  half-glass  of  the  Ems 
water,  and  in  the  morning  sponging  of  the  whole  body  with  water 
at  the  temperature  of  22°  to  18°  B.  (about  82°  to  67° i^.).  Hy- 
giene in  general  and  the  diet  in  particular  strictly  regulated : 
quantity  and  quality  of  food  and  drink  is  limited  and  precisely 
designated  —  to  be  taken  frequently,  but  little  at  a  time.  He 
was  advised  to  gradually  rid  himseK  of  the  habit  of  washing  his 
stomach  :  to  do  gastric  lavage  at  first  twice  a  week,  then  once, 
and  later  to  discontmue  it  altogether.  In  about  eight  weeks  of 
such  treatment  (the  potassium  bromide  was  discontinued  before 
that  time),  the  patient  could  get  along  without  lavage,  and  im- 
proved considerably :  there  remained  only  slight  retching  and 
some  inclination  toward  constipation ;  the  pain  and  heavi- 
ness in  the  gastric  region,  as  well  as  the  nausea,  disappeared; 
both  sleep  and  mental  condition  improved.     A  prolonged  sail 


—  136  — 

on  a  Volga  steamer  brought  about  a  complete  return  to 
health. 

Finally,  there  are  cases,  where  the  emploj^ment  of  gastric 
lavage,  in  nervous  dyspepsia,  is  wrongly  applied. 

Take  such  a  case.  Some  ten  years  ago  there  was  admitted  to 
our  clinic  a  medical  student  of  the  senior  class,  with  a  strongly 
develoj)6d  neurasthenia  and  nervous  dyspepsia.  The  physician 
whom  he  consulted  before  his  admission  to  the  clinic,  found  a 
"  splash  "  in  his  abdomen,  and  concluded  that  the  patient  suffered 
with  dilatation  of  the  stomach,  requiring  gastric  lavage.  Ex- 
amination of  the  patient  failed  to  elicit  any  symptoms  of  dilata- 
tion of  the  stomach  :  the  abdomen  proved  to  be  equably  and  pro- 
nouncedly sunken  everywhere ;  but  to  quiet  the  frightened  patient 
a  sound  was  introduced :  the  stomach  proved  to  be  empty,  which 
fact  raised  the  patient's  spirits  considerably ;  while  the  sub- 
sequent treatment,  with  cold  water  douches  and  silver  nitrate, 
soon  removed  the  phenomena  of  neurasthenia  and  of  nervous  dys- 
pepsia. Or  here  is  another  case  (a  later  supplement).  Patient, 
thirty-six  j'ears  old,  of  good  constitution,  was  admitted  to  our 
clinic  April  Tth,  1890,  complaining  of  heaviness  in  the  region 
of  the  stomach  and  belching,  of  constipation  and  pains  in  the 
abdomen,  which  proved  on  mquiry  to  be  of  intestinal  origin,  of 
poor  sleep  and  oppressed  mental  state.  Anamnesis :  Until  his 
twenty-ninth  year  patient  enjoyed  good  health;  at  this  age  he 
passed  through  an  attack  of  t}^hoid,  which  left  him  in  a  weak- 
er condition  than  he  was  before.  Later  there  were  superadded 
some  other  influences  imfavorable  to  health :  the  patient,  who 
formerly  used  to  bathe  with  apparent  benefit  to  his  health,  had 
to  give  up  bathing  on  account  of  change  of  residence  and  ab- 
sence of  a  suitable  bathing  place ;  he  began  to  be  intensely 
preoccupied  in  the  capacity  of  a  manager  of  an  estate,  and  to  all 
this  were  finally  added  certain  family  troubles.  Under  such 
conditions  there  appeared,  two  years  ago,  belching,  heavmess  m 
the  stomach,  constipation  and,  later,  intestinal  pains.  Patient 
began  to  be  treated,  took  at  various  times  hydrochloric  acid, 
pepsm,  bismuth,  carbolic  acid,  resorcin,  soda  powders,  for  a 
short  time  silver  nitrate,  and,  for  a  shorter  period  still  (eight 
days),  arsenic  —  but  all  these  failed  to  bring  any  relief.     During 


—  137  — 

December,  1889,  and  in  January  and  February,  1890,  he  had  been 
given  about  sixty  ivashings  of  the  stomach,  which  failed  to  alleviate 
his  condition  in  the  very  least.  During  February  and  March 
the  patient  drank  Vichy,  cold  and  aft€r  meals,  also  without 
success. 

Mode  of  living.  ■ —  Patient  lives  in  a  healthy  locality  and  re- 
sides in  a  good  house.  Does  not  bathe  in  the  sea,  takes  baths 
at  home  but  rarely.  Smokes  little ;  does  not  drink  anj-  beer. 
wine  or  brandy ;  drinks  some  five  to  six  glasses  of  weak,  warm 
and  unsweetened  tea  per  day ;  drinks  neither  water  nor  kvass  ; 
eats  two  light  meals  a  day ;  keeps  no  fast  days.  He  is  smgle. 
This  last  year,  on  account  of  indisposition  or,  rather,  considering 
himself  sick,  he  gave  up  his  occupation,  which  fact  tends  to 
more  aggravate  his  oppressed  mental  state. 

Status  presens.  —  Appetite  somewhat  worse.  There  is  a  con- 
stant heavmess  at  the  pit  of  the  stomach  and  light  belching  of 
odorless  gases,  both  after  meals  and  on  an  empty  stomach ;  there 
were  neither  m  the  past,  nor  are  there  at  present,  any  pj-rosis, 
nausea,  vomiting,  and  pam  at  the  pit  of  the  stomach,  neither 
spontaneous  nor  on  pressure.  Being  costive,  patient  resorts 
often  to  laxatives,  as  pulvis  liquiritise  compos.  Intestinal 
pains.  Abdomen  somewhat  distended.  The  liver,  spleen,  the 
kidneys,  the  organs  of  respiration  and  of  circulation  present 
nothhig  abnormal.  Patient  grew  thin.  The  sleep  is  poor,  the 
mental  condition  oppressed. 

Treatment.  — The,  symptoms  of  neurasthenia  and  of  nervous 
dyspepsia,  so  marked  even  on  his  admission,  became  so  promi- 
nent durmg  the  first  days  of  the  patient's  stay  in  the  clinic,  that 
we  ordered  hydrotherapj'  (douches,  from  22  to  18°it.  (81.5  to 
12.5°F.'),  to  the  exclusion  of  any  other  treatment.  There  fol- 
lowed a  rapid  simultaneous  improvement  in  all  the  symptoms : 
as  heaviness  at  the  pit  of  the  stomach,  belching,  constipation, 
intestinal  pains,  msonmia  and  oppressed  mental  condition. 
Patient  left  the  clinic  April  30th,  almost  completely  improved. 

He  was  advised  to  make  this  improvement  durable  by  summer 
bathing  and  by  a  correct  mode  of  living,  and  among  other  things, 
also  by  a  return  to  his  occupation,  but  without  unduly  exerting 
himself 


—  138  — 

FROM  THE  LECTURE  OF  NOVEMBER  28,   1889. 

Five  weeks  passed  since  we  saw  the  patient  last.  Up  to 
November  17th,  he  drank  the  Ems  water  and  took  drops  of  the 
tincture  of  nux  vomica  ;  had  at  times  clysters,  and  but  very 
seldom  resorted  to  codeine.  Since  the  17th,  he  is  given  pills  of 
silver  nitrate,  at  iirst  one-twentieth-grain  twice  a  day  at  meal- 
time, and  since  November  2 2d,  three  times  a  day.  For  the 
last  several  days  he  has  had  general  massage.  Patient  desires 
to  leave  the  clinic  to-morrow.  His  condition  has  improved  con- 
siderably. The  appetite  is  good ;  patient  gets  durmg  the  day  a 
pound  of  bread,  six  eggs,  two  glasses  of  bouillon,  three  to  four 
glasses  of  milk-soup  with  manna  (patient  refuses  meat),  and 
at  times  begs  for  more  food.  Of  the  gastric  symptoms  there 
remained  some  heaviness  at  the  pit  of  'the  stomach,  at  times  easy 
belching,  and,  very  seldom,  slight,  rapidly  passing  pains,  that  do 
not  require  any  codeine.  He  is  somewhat  costive,  and  must  at 
times  resort  to  clysters.  The  tenderness  on  pressure  in  the 
region  of  the  ccecum  and  ascending  portion  of  the  colon  dis- 
appeared. Pulse  is  good.  His  nutrition  has  improved  markedly. 
Has  eight  hours  of  quiet  sleep.  Mental  condition  better;  he 
feels  stronger.  Patient  was  advised,  besides  a  strict  persever- 
ance in  a  correct  mode  of  livmg  and  circumspection  in  move- 
ments and  exertion,  to  continue  the  treatment  by  silver  nitrate 
and  the  general  massage. 


THIRD  CASE 


LECTURE  OF  NOVEMBER  3,  1889. 

The  patient,  a  student,  twenty-two  years  old,  complains  of 
abdominal  pains  and  constipation,  which  is  at  times  replaced  by 
a  diarrhoea  ;  of  palpitation  and  of  unpleasant  sensations  in  the 
region  of  the  heart,  of  pains  in  the  head  and  spine,  and  of  poor 
sleep  ;  he  is  quickly  fatigued  b}'  physical  and  mental  exertion  and 
is  in  a  despondent  mood:  he  is  always  disturbed  by  various 
anxieties,  but  chiefly  by  the  apprehension,  that  he  suffers  from 
an  "  organic  heart  trouble." 

Circumstmices  and  mode  of  living.  —  For  the  last  four  years 
patient  lived  continuously  m  Moscow,  summer  and  winter. 
Lodgings  fair,  water-closet  cold ;  he  formerly  used  to  bathe 
himself,  but  has  not  done  so  lately,  as  bathing  would  chill  him 
and  cause  attacks  of  cardiac  palpitation.  He  does  not  go  to 
public  baths,  but  washes  himself  at  home.  Drmks  but  little  tea, 
and  neither  coffee  nor  wine.  Smoked  before,  but  has  discon- 
tinued it  now,  as  it  brought  on  palpitation  of  the  heart.  Order  of 
meals :  breakfast,  tea  with  bread  in  the  morning,  dinner  and  sup- 
per ;  his  board  was  always  good,  with  the  exception  of  a  period  of 
two  weeks,  of  which  more  later.  The  patient  is,  as  I  said,  a 
student,  and  also  a  private  tutor.  He  goes  out  of  doors  for  two 
hours  daily.     Has  enough  time  for  sleep,  from  11  p.  m.  to  8 

A.  M. 

Anamnesis.  —  His  parents,  according  to  his  statement,  are 
healthy.  While  yet  in  the  gymnasium  (high  school),  some  ten 
years  ago,  the  patient  suffered  from  constipation,  otherwise  en- 
joyed fair  health  up  to  the  time  he  took  up  his  residence  in 
Moscow,  when  the  constipation  increased  and  the  patient  began 
to  grow  somewhat  thin  and  weak.  He  passed  through  an  attack 
of  acute  articular  rheumatism  some  three  years  ago,  but  it  was  of 


—  140  — 

a  light  character  (he  not  being  confined  to  bed  during  the  attack) 
and  it  passed  away  in  a  few  days  with  the  aid  of  sodium  salycil- 
ate ;  since  then  he  suffers  with  palpitation  of  the  heart.  About 
one  year  ago  his  sleep  became  poor,  mental  condition  gloomy, 
the  weakness  more  pronounced,  the  attacks  of  palpitation  were 
accompanied  by  unpleasant  sensations,  and  at  times  even  by 
pains  in  the  region  of  the  heart.  All  these  phenomena  became  ag- 
gravated because  of  an  affliction,  which  the  patient  had  suffered 
some  three  months  ago.  A  month  ago  the  patient  was  compelled 
to  have  bad  meals,  which  caused  a  diarrhoea  ;  this  was  stopped  at 
first  by  tra.  opii,  but  it  reappeared  again ;  since  then  the  patient 
would  either  be  constipated  for  three  or  four  days,  or  would  have 
three  or  four  stools  a  day,  with  pain  m  the  abdomen,  of  liquid 
consistency  and  with  an  admixture  of  mucus.  He  had  a  diarrhoea 
when  he  was  admitted  to  our  clinic,  October,  29th.  He  was 
given  five  di'ops  of  the  tincture  of  opium ;  the  abdomen  was 
wrapped  in  flannel,  and  one-half  glass  of  hot  Ems-Kesselbrunnen 
water  was  prescribed  for  him  to  be  taken  in  the  morning  on  an 
empty  stomach,  one  hour  before  his  tea,  and  a  tablespoonful  of 
the  decoction  of  condurango  (3ij  to  fiij)  with  five  drops  of  the 
tincture  of  nux  vomica  after  dinner  and  supper ;  a  clyster  m 
case  of  constipation  and,  after  the  diarrhoea  stopped,  one  day 
static  electricity  ("  the  bath"  —  i.  e.  sitting  on  the  insulated 
chair  at  the  time  of  the  seance),  the  next  day  general  massage, 
excepting  the  abdomen  ;  later  on,  cold  water  treatment.  He  was 
enjoined  to  avoid  physical  and  mental  fatigue  —  to  read  but 
little ;  while  the  diarrhoea  lasted  he  had  tea  for  a  drink ;  of  the 
food  we  will  speak  later. 

Status.  —  Patient  is  of  average  physical  stature  and,  contrary 
to  his  assertions  that  he  grows  thin,  his  nutrition  is  quite  satis- 
factory :  the  subcutaneous  adipose  tissue  is  quite  considerable, 
and  the  muscles  are  well  developed.  The  appetite  and  the  gas- 
tric digestion,  as  the  patient  claims,  are  very  changeable :  on  the 
days  when  he  has  a  good  rest,  and  when  his  mental  condition  is 
good,  he  eats  well  without  experiencing  any  unpleasant  after- 
effects ;  but  after  a  poor  sleep,  and  when  feeling  poorly,  he  eats 
little  and  still  experiences  a  painful  sensation  at  the  pit  of  his 
stomach,  that  passes  away  only  after  painful  and  prolonged  belch- 


—  141  — 

ing.  Until  the  appearance  of  the  diarrhoea  he  experienced  no 
other  unpleasant  sensations  in  the  abdomen ;  but  with  the  diar- 
rh(Ea  there  appeared  also  intestinal  pains.  After  his  admission 
to  the  clinic  the  diarrhoea  ceased  and  the  intestinal  pains  have 
almost  disappeared.  He  had  yesterday  a  water  clyster,  that  in- 
duced a  satisfactory  evacuation  after  a  constipation  of  two  days' 
duration ;  the  abdomen,  however,  is  somewhat  distended  and 
slightly  sensitive  to  examination,  which  latter  causes  some  gur- 
gling. We  are  unable  to  detect  any  particular  tenderness  or 
generally  anything  abnormal  in  the  regions  of  the  stomach,  liver, 
spleen  and  kidneys.  The  urine  is  normal.  The  patient  was  for  a 
long  time  very  intemperate  m  his  sexual  relations  ;  the  erections 
are  now  weaker,  he  himself  feeling  weaker  after  the  acts  of  copu- 
lation, although  he  performs  them  less  frequently  than  formerly. 
He  had  two  attacks  of  gonorrhoea,  which  passed  without  leaving 
a  trace,  but  had  aggravated  his  disturbed  mental  state.  He  is 
free  from  syphilis.  —  Some  dyspnoea  on  walkmg.  Pulse  normal, 
except  durmg  the  above-mentioned  attacks  of  palpitation  with 
pain  in  the  region  of  the  heart,  when  it  is  considerably  quickened. 
Objective  examination  elicits  nothing  abnormal  in  the  respiratory 
organs,  heart  and  blood-vessels,  as  well  as  in  the  chest,  with  the 
exception  of  a  small  area  of  cutaneous  hypersesthesia  around  the 
left  nipple,  an  area  smaller  than  that  of  the  region  of  the  heart, 
where  the  patient  experiences  pain  during  the  severe  attacks  of 
palpitation.  Fever  absent.  The  nervous  phenomena  are  exact- 
ly pictured  in  the  complaints  of  the  patient  and  in  the  anamnesis. 
Headaches,  when  the  patient  is  constipated,  are  experienced  in 
the  occipital  region,  while  after  mental  exertion,  in  the  frontal 
part ;  at  times  slight  migraine.  The  pains  along  the  spine  seem 
to  be  due  to  cutaneous  hypergesthesia  in  the  region  of  several 
vertebrae.  All  the  movements  of  the  spine  are  perfectly  free 
and  painless.     Reflexes  considerably  increased. 

As  the  lecture  draws  to  a  close,  we  will  take  up  the  diagno- 
sis later ;  and  now  a  few  words  about  the  treatment.  After 
having  ingested  poor  food,  the  patient  suffered  from  an  attack 
of  diarrhoea,  evidently  due  to  an  intestinal  catarrh,  for  the  pain- 
ful evacuations  were  mixed  with  mucus :  it  is  likely,  that  the 
gastric  catarrh  also  began  then,  and  that  the  dyspeptic  gastric 


—  142  — 

phenomena  depend,  to  some  extent  at  least,  on  the  catarrh ;  we 
therefore  prescribed  Ems,  but  in  view  of  the  diarrhsea,  only  one- 
half  glass  in  the  morning,  and  very  warm.  The  mdication  for 
condurango  and  the  tincture  of  nux  vomica,  which  proved  of 
such  advantage  in  both  constipation  and  diarrhoea,  as  you  know 
from  the  analysis  of  the  first  case,  requires  no  explanation,  when 
employed  for  a  patient,  who  suffers  alternately  from  diarrhoea 
and  constipation.  The  indications  for  the  use  of  electricity,  mas- 
sage and  hydrotherapy  will  be  spoken  of  later,  after  the  final 
diagnosis  has  been  arrived  at. 


LECTURE  OF  NOVEMBER  7,  1889. 

Status.  —  Patient's  condition  improved  all  around.  Appetite 
and  digestion  are  such  that  for  the  last  three  daj's  he  is  given  daily 
two  plates  of  chicken  soup,  three-fourths  of  a  chicken,  over  one- 
half  pound  of  roast  meat,  six  eggs  and  about  one  pound  of  white 
bread ;  he  takes  all  this  at  four  meals,  and,  outside  of  slight  heavi- 
ness and  belching,  and  even  this  rarely,  not  after  each  meal,  he 
suffers  from  no  dyspeptic  phenomena.  Such  a  condition  after 
only  a  five  days'  use  of  Ems,  and  of  but  one-half  glass  of  it  per 
day,  speaks  against  catarrh  of  the  stomach,  the  more  so  against 
ulcer  or  cancer,  especially  if  you  recollect  the  slow  improvement 
in  the  appetite  and  ui  the  nutrition  with  the  more  energetic  and 
continuous  treatment  and  very  strict  diet  in  our  previously  dis- 
cussed case  of  a  real  catarrh  of  the  stomach ;  it  also  excludes 
dilatation  of  the  stomach,  as  the  evacuations,  though  with  the 
aid  of  clysters,  are  sufficient.  The  abdomen  is  less  distended 
and  not  tender.  He  had  almost  no  cardiac  attacks  during 
these  days.  He  sleeps  better,  although  not  every  night.  His 
mental  state  is  calm,  especially  after  I  examined  and  positively 
assured  him  that  he  had  no  organic  heart  lesion,  and  that  his 
malady  was  perfectly  curable.     There  is  also  less  weakness. 

Before  taking  up  the  final  diagnosis,  we  will  say  a  few  words 
about  the  treatment,  as  indicated  by  the  present  condition  of  the 
patient.  As  there  is  no  gastric  catarrh,  we  will  discontinue  the 
Ems   water,  but  will  continue   the  condurango  and  the  nux  vo- 


—  143  — 

mica,  for  there  is  still  at  times  a  feeliiig  of  heaviness  in  the 
stomach  and  some  belching;  besides,  the  diarrhoea  has  only 
ceased  recently  and  the  constipation  continues  as  yet.  Frank- 
linization and  massage  acted  well  on  the  patient ;  but  the  ces- 
sation of  the  diarrhoea  requires  hydrotherapy  instead.  We  will 
also  prescribe  for  the  patient  silver  nitrate  (one  grain  in  twenty 
pills  with  extract  trifolia),  at  the  beginnnig  twice  a  day,  imme- 
diately before  each  meal.  As  the  sleep  is  not  as  yet  always 
sound,  and  the  disappearance  of  the  diarrhoea  permits  of  the  use 
of  bromides,  we  will  resort  to  these  if  necessary.  The  reason 
for  the  employment  of  silver  nitrate  and  of  the  bromides  will  be 
made  clearer  after  the  final  diagnosis,  when  we  will  take  up  the 
whole  plan  of  treatment. 

Diagnosis.  It  is  evident,  from  what  was  pointed  out  above, 
that  catarrh,  dilatation,  ulcer  and  cancer  of  the  stomach  may 
positively  be  excluded  in  this  case ;  while  the  change  in  the  ap- 
petite and  in  the  dyspeptic  phenomena,  and  their  close  connec- 
tion with  the  general  nervous  condition  go  to  show,  that  the 
patient  suffers  from  nervous  dyspepsia.  Besides  the  gastric 
there  are  also  present  morbid  intestmal,  cardiac  and  general  ner- 
vous symptoms.  We  will  begm  with  the  general  nervous  symp- 
toms, as  even  you,  though  beginners,  will  easily  perceive  from 
the  data  collected  by  observation  and  objective  investigation, 
that  they  are  the  most  important  in  this  case. 

To  better  elucidate  the  importance  of  the  morbid  nervous  phe- 
nomena in  this  patient,  I  must,  refer  you  to  what  I  said  regarding 
the  condition  of  the  nervous  system  in  our  first  case.  (  Vide  pp. 
7  0-72.)  From  a  careful  comparison  of  the  two,  you  will  perceive 
that  our  present  case  is  just  the  opposite  of  that  one  :  in  the  pres- 
ence of  a  good  constitution  and  nutrition,  of  a  normal  condition 
of  all  the  organs,  except  the  nervous  system  (the  trifling  diarrhcea 
appeared  only  recently,  while  the  constipation  and  the  cardiac 
phenomena  are,  as  we  shall  see  later,  of  a  neurasthenic  origin). 
The  patient  leading  a  life  amidst  mcomparably  better  surround- 
ings, there  appeared  a  primary,  obstinate,  progressive  neuras- 
thenia, its  sum  total  of  symptoms  having  been  made  clear 
by  inquiry  and  by  objective  examination.  It  is  a  case  of  genu- 
ine,  typical,  although  not  extremely  developed,  neurasthenia. 


—  144  — 

A  s  far  as  its  origin  is  concerned,  we  know  nothing  definite  of  the 
influence  of  heredity,  while  the  factors  that  caused  its  appear- 
ance are  patent ;  thus :  a  three  years'  residence,  during  both 
winter  and  summer,  in  a  great  city,  conjoined  with  considerable 
uninterrupted  mental  labor  (private  tutoring  even  in  summer), 
lack  of  bathing  all  this  time,  worries,  but  certainly  most  impor- 
tant of  all,  extreme  intemperance  in  sexual  relations  and  also 
the  attacks  of  urethritis.  In  extreme  cases  of  genuine  neuras- 
thenia, it  is  necessary  to  call  to  aid  the  differential  diagnosis 
from  hysteria  and  even  from  multiple  sclerosis.  But  in  this 
moderately  developed  case,  where  the  distinction  from  these  dis- 
eases is  so  very  evident,  such  procedure,  a  differential  diagnosis, 
would  be  but  a  waste  of  time.  Although  our  patient  had  an 
attack  of  acute  articular  rheumatism  —  a  very  slight  attack  and 
of  short  duration  —  but  in  the  presence  of  the  perfectly  normal 
condition  of  the  organs  of  circulation,  the  morbid  phenomena 
met  with  in  this  case  in  the  sphere  of  the  plexus  cardiaci,  as 
palpitation  and  pain  in  the  region  of  the  heart,  must  be  referred 
to  the  neurasthenia,  of  which  they  constitute  a  very  frequent 
symptom. 

The  constipation,  that  is,  the  weakening  of  the  nervo-muscu- 
lar  apparatus  of  the  intestines,  was  at  the  beginning  due  to  his 
neglect  to  attend  to  the  calls  of  nature  while  yet  in  high  school. 
With  the  development  of  general  neurasthenia  this  condition  of 
the  intestines  naturally  became  more  aggravated.  The  intesti- 
nal catarrh,  which  appeared  about  a  month  ago,  was  the  cause 
of  the  origin  of  the  diarrhoea,  and  since  that  time  the  intestines 
presented  a  picture  of  two  contemporaneously  existing  morbid 
conditions  —  of  the  weakness  of  their  nervo-muscular  apparatus 
and  of  a  catarrh  of  their  mucous  membrane. 

Progyiosis.  —  Whether  or  not  our  patient  has  an  innate  pre- 
disposition to  neurasthenia  cannot  be  asserted  with  certainty ;  but 
even  if  it  be  present,  it  is  hardly  of  any  considerable  extent :  the 
data,  obtamed  by  the  investigation,  show,  that  up  to  a  certain 
period,  almost  up  to  the  time  he  entered  the  university,  the  pa- 
tient had  no  symptoms  of  weakened  nervous  activity ;  these 
latter  began  to  develop  only  after  the  following  evident  causes 
appeared,  tending  to  neurasthenia,  namely :  constant  residence 


—  145  — 

and  constant  occupation  (also  during  summer^  in  a  great  city, 
lack  of  bathing,  to  which  he  was  habituated  before,  worries  of 
various  nature,  and  chiefly  —  sexual  intemperance.  In  such 
cases,  that  is,  where  there  is  no  mnate  and,  besides,  obstinate, 
difficultly  removable  weakness  of  the  nervous  system,  but  where 
the  neurasthenia  is  acquired  and  is,  as  in  our  patient,  not 
extremely  developed,  a  perfect  cure  is  possible  ;  but  the  stability 
of  the  cure,  and  the  absence  of  recurrent  attacks  will  certainly 
depend  on  the  will-power  and  the  ability  on  the  part  of  the 
patient  to  avoid  the  influences,  that  give  rise  to  neurasthenia. 
Treatment.  —  We  will  begin  with  the  principal  ailment  m  the 
present  case,  the  disease  of  the  nervous  system,  neurasthenia. 
As  what  concerns  his  hygiene,  we  will  chiefly  advise  the  patient, 
first  of  all,  to  shorten  at  once  his  occupations  and  return  to  his 
native  place,  there  to  stay  until  the  beginning  of  the  future 
semester,  in  the  middle  of  January ;  then  to  entirely  discontinue 
his  work  for  at  least  one  month  every  summer,  while  residing  as 
long  as  possible  in  a  pleasant  suburban  locality,  to  bathe  in  the 
s-ea  or  river,  to  take  due  care  of  his  sleep,  not  to  interfere  with 
it  (as  for  instance,  by  an  unnecessary  meal  or  fatiguing  mental 
work  immediately  before  going  to  bed),  nor  to  shorten  it,  —  to 
sleep  just  as  long  as  necessary ;  to  work  only  after  a  sufficient 
rest,  and  never  to  fatigue  himself  either  physically,  or  mentally. 
We  will  advise  complete  abstinence  from  sexual  intercouse  — 
the  most  important  cause  of  the  morbid  condition  in  the  present 
case.  Unfortunately  the  advice  of  the  physician  concerning  this 
matter  is  not  always  followed ;  but  it  were  erroneous  to  think, 
that  it  is  never  followed,  and  that  it  would  therefore  hardl}- 
be  worth  while  giving  it.  On  the  contrary,  a  sensible,  decisive 
and  friendly  advice  will  not  be  followed  rather  in  the  minority 
of  cases,  but  if  followed,  it  will  be  of  mestimable  value  to  the 
patient,  which  is  the  most  important  aim  of  the  physician's 
practice  in  such  cases.  Nor  is  the  fulfilling  of  this  advice  as 
difficult  or  impossible,  as  the  patients,  of  whom  we  speak, 
usually  think,  if  the  physician  but  teach  them  to  avoid  sexual 
excitement  through  physical  mfluences  (as  constipation,  soft 
bedding,  tight  clothing,  alcoholic  chinks,  etc.),  as  well  as  through 
influences  acting  in  a  psychical  manner  (lascivious  thoughts,  cer- 


—  146  — 

tain  books,  certain  male  and  female  society),  and  if  he  explain  to 
the  patients  the  harm  in  such  cases  of  insufficient  physical  activ- 
ity, of  mental  idleness,  of  lack  of  aesthetic  impressions  and,  first 
of  all,  impress  upon  them  their  moral  and  religious  duties.  Be- 
sides, our  patient  is  twenty-two  years  old  and  in  a  year  and 
a  half  he  will  graduate  from  the  University;  consequently  in 
the  near  future  we  may  expect  that  he  will  marry. 

The  best  of  all  the  non^apotheeary  means  for  the  treatment 
of  neurasthenia  is  hydrotherapy,  and  in  proportion  as  the  patient 
is  young  and  the  condition  of  the  internal  organs  and  that  of 
nutrition  is  good,  and  the  more  the  nervous  disturbances  have 
the  character  of  nervous  depression,  the  more  applicable  is 
cool  or  cold  water ;  on  the  contrary,  if  the  patient  is  older,  and 
the  apprehensions  excited  by  the  condition  of  this  or  that  inter- 
nal organ  are  great,  while  the  condition  of  nutrition  is  bad  and 
the  more  the  nervous  disturbances  have  the  character  of  excite- 
ment, —  mental  (total  insomnia,  anxious  mental  state)  and 
physical  (hypereesthesia,  pains  and  spasmodic  attacks  of  nausea 
and  palpitation,  hampered  and  quickened  respiration), — the 
more  applicable  is  warm  water.  I  usually  devote  two  lectures, 
at  the  end  of  the  year,  to  clinical  balneotherapy  —  to  balneothera- 
py for  the  practical  physician,  and  I  will  discuss  then  the  subject 
in  a  more  detailed  manner ;  but  what  I  have  already  said  is  sufficient 
to  show,  that  for  x)ur  patient  cool  (and  later  cold)  water  is  more 
suitable  than  warm  water.  One  of  the  best,  if  hot  the  best,  way 
of  applying  cold  water  to  patients  of  quite  strong  constitution, 
as  in  the  case  of  our  patient,  is  in  the  form  of  fan-like  douches 
under  high  pressure,  applied  over  the  whole  surface  of  the  body, 
except  the  head,  on  which  a  cold  compress  is  placed.  The  diar- 
rhoea did  not  permit  until  now  of  the  employment  of  these 
douches,  and  we  therefore,  out  of  the  non-apothecary  means, 
used  only  general  massage  and  electricity. 

General  massage  is  by  far  not  as  reliable  in  the  treatment  of 
neurasthenia,  as  hydrotherapy  is :  for  cases  of  neurasthenia  of  the 
nature  of  excitement,  with  hysteroid  symptoms,  massage  is  as 
unsuitable  as  it  is  in  pure  hysteria,  and  sometimes  simply  impos- 
sible of  application,  for  instance,  in  cases  with  considerable  hyper- 
sesthesia.     But  in  our  patient,  in  view  of  the  fact,  that  the  symp- 


—  147 


toms  bearing  the  character  of  depression  prevail,  that  the 
hypersesthesia  is  insignificant,  either  by  its  intensity,  or  by  the 
extent  of  the  affected  area,  in  view  of  the  chillines  of  the  patient 
and  the  trifling  amount  of  physical  exercise  prescribed  for  him, 
and  consequently  partly  to  replace  this  last,  we  resorted  to 
general  massage,  and,  as  we  said  before,  the  results  have  justi- 
fied our  expectations. 

Electricity,  particularly  static  and  galvanic,  is  shown  from  ex- 
perience to  be  beneficial  in  neurasthenia,  but  not  alwaj's  so. 
We  cannot  give  any  precise  mdications  for  its  employment :  ex- 
perience decides  as  to  whether  it  is  beneficial  or  not,  and  as  to 
which  form  is  to  be  employed  —  static  or  galvanic  (either  one 
or  the  other)  ;  we  have  tried  the  static,  and  as  it  proved  to 
exert  a  good  effect  on  the  nervous  disturbances  from  which  our 
patient  suffers,  we  did  not  change  it. 

At  present,  when  the  diarrha?a  has  ceased,  the  intestinal  pains 
have  finally  cUsappeared  and  the  abdomen  became  free  from  pain, 
we  will  leave  off  massage  and  electricity  and  will  use  the  dou- 
ches, m  the  beginnmg  at  28°i?.  (about  97°^.)  and  later  at  a  lower 
temperature. 

The  chief  apothecary  remedies  used  in  neurasthenia  are  silver 
nitrate,  arsenic  and  iron.  The  last  is  suitable  in  cases  of  neu- 
rasthenia with  a  strongly  pronounced  ansemia,  which  is  more 
frequently  seen  in  women  than  in  men.  For  our  patient  iron 
is  not  only  not  indicated,  as  he  has  no  symptoms  of  aneemia, 
but  is  rather  contraindicated,  as  it  may  easily  impair  the  appe- 
tite and  cause  constipation,  from  which  the  patient  is  alreadv 
suffermg.  Arsenic  is  suitable  for  cases  of  neurasthenia  in 
which  the  patient's  appetite  is  poor  and  his  nutrition  has  failed 
greatly ;  our  patient's  appetite,  although  changeable,  is  never- 
theless most  of  the  time  good,  his  nutrition  suffered  but  little, 
while  the  recently  ceased  diarrhoea  constitutes  a  contraindication 
to  the  employment  of  arsenic,  as  this  last  causes  a  diarrhoea  so 
easily.  Silver  nitrate  is  particularly  beneficial  in  those  cases  of 
neurasthenia  in  which  the  morbid  phenomena  of  the  nature  of 
depression  prevail,  as  in  our  patient ;  it  too  tends  somewhat  to 
costiveness,  but  not  at  all  to  the  extent  and  frequency,  as  is  the 
case  with  iron,  nor  does  it  impair  the  appetite  in  the  least.     It 


—  148  — 

therefore  becomes  apparent  to  you  why  we  employed  silver  ni- 
trate. 

Is  it  always  necessary  to  employ  two  or  more  remedial  agents 
in  neurasthenia,  as  we  do  in  the  present  case  —  silver  nitrate 
and  hydrotherapy?  Certamly  not  always  :  for  cases  of  moder- 
ately developed  and  recent  neurasthenia  in  robust  young  men 
it  is  sufticent  —  especially  in  summer,  when  a  prolonged  stay 
out-of-doors  is  possible  —  to  observe  the  hygiene  and  hydrothe- 
rapy, for  example,  in  the  form  of  river,  or  still  better,  sea-bath- 
ing. The  neurasthenia  in  our  patient  is  quite  severe  and  of  long- 
standing, the  season  of  the  year  now  is  the  beginning  of  winter ; 
besides,  the  patient  contemplates  returning  soon  to  his  own 
home,  where  he  will  not  be  able  to  be  benefited  by  the  use  of 
such  strong  fan-like  douches  and  under  high  pressure,  as  he  has 
in  our  clmic,  but  will  replace  them  by  a  hand-douche  from  a 
pump,  acting  certainly  much  weaker ;  this  was  the  reason  for 
our  prescribing  for  the  patient  hydrotherapy  and  silver  nitrate 
at  one  and  the  same  time. 

If  the  above-named  remedial  agencies,  very  good  though  they 
be  for  neurasthenia,  will  not  act  with  sufficient  rapidity  —  which 
is  very  possible  in  the  given  case  of  such  obstinate  neurasthenia, 
—  and  will  not  with  sufficient  rapidity  remove  certain  particu- 
larly burdensome  morbid  phenomena,  dependent  on  neurasthenia 
and  in  their  turn  prolonging  it,  principally  the  poor  sleep,  then 
we  will  order  symptomatically  bromides  (15  grains  of  sodium 
bromide  m  case  of  insomnia),  until  the  prmcipal  treatment, 
hydrotherapy  and  silver  nitrate,  which  we  may  call  radical,  will 
securely  remove  also  the  insomnia  together  with  the  other 
symptoms  of  neurasthenia.  The  bromide  preparations,  some  of 
the  best,  if  not  the  best,  somnifacient  agencies,  are  particularly 
indicated  in  the  given  case  also  by  the  gloomy  and  worrying  men- 
tal state  as  well  as  by  the  morbidly  excited  sexual  sphere  (lascivi- 
ousness  and  a  tendency  to  pollutions).  I  must  also  observe, 
that  the  bromides,  as  any  other  symptomatic  and  palliative 
means,  must  be  ordered  with  extreme  caution,  just  in  quantities 
required  by  the  necessity  of  the  case.  The  abuse  of  symptom- 
atic and  palliative  remedies  is  the  true  sign  of  a  poor  physician, 
who  is  either  unable  to  comprehend  the  case  and  to  order  the 


—  149  — 

radical  treatment,  or,  what  is  more  frequent,  who  is  rather 
annoyed  at  the  necessity  of  fulfilling  this,  his  duty. 

The  cardiac  phenomena,  since  the  patient's  apprehensions 
about  his  heart  had  been  allayed  and  he  generallj^  feels  better, 
have  become  so  quiet,  that  they  require  no  particular  treatment. 

The  diarrhoea  has  disappeared,  and  there  remain  only  some 
trifling  dyspeptic  phenomena,  at  times  slight  heaviness  and 
belching,  and  some  constipation.  Of  the  treatment  of  the  con- 
stipation next  time. 


LECTURE  OF  NOVEMBER  28,  1889. 

Before  discussmg  the  treatment  of  the  gastro-intestinal  dis- 
turbances in  neurasthenics,  let  us  see  whether  there  is  only 
one  variety  of  gastric  nervous .  dyspepsia,  and  whether  this 
variety  is  always  to  be  met  m  the  form  we  see  it  in  our  patient. 
The  theoretical  attempts  to  create  various,  very  numerous  forms 
of  nervous  dyspepsia,  basing  their  classification  upon  the  as- 
sumed heightened  or  lowered  activity  of  the  gastric  nerves  — 
sensory,  motor,  and  secretory,  —  have  all  failed ;  but  practice 
has  proved  the  existence  of  at  least  two  varieties  of  nervous 
dyspepsia  :  one,  the  most  frequent,  such  as  seen  in  the  present 
case  (its  prmcipal  symptoms  —  a  feeling  of  heavmess  after  a 
meal  and  belching),  observed  in  neurasthenia  with  the  character 
of  depression ;  the  other,  less  frequent,  of  which  the  chief  symp- 
toms consist  of  severe  pains  in  the  region  of  the  stomach  (car- 
dialgia  and  gastralgia  proper),  followed  by  tormenting,  very 
sour  belching  and  nausea,  accompanied  frequently  by  contem- 
poraneous attacks  of  severe  migraine.  This  variety  is  usually 
seen  in  neurasthenia  with  the  character  of  excitement.  The 
treatment  and  partly  the  diet  differ  in  either  of  the  varieties  of 
nervous  dyspepsia. 

When  ordering  a  diet  for  nervous  dyspepsia,  we  must  be 
guided,  as  has  already  been  explamed  in  discussing  our  first 
case,  besides  the  general  physiological  and  dietetic  considerations, 
also  by  the  mdividuality  of  the  given  case.  Generally  speak- 
ing, for  cases  of  pure  nervous  dyspepsia,  uncomplicated  by  any 


—  150  — 

otlier  disease  of  the  stomach,  the  "  delicate  "  food  given  for 
gastric  catarrh  is  unsuitable ;  rather,  on  the  contrary,  we  must 
order  food  which  is  more  prone  to  excite  a  sufficient  excretion 
of  the  gastric  juice  •  however,  m  cases  of  the  above-named  sec- 
ond variety  of  nervous  dyspepsia,  careful  observation  in  the 
administration  of  such  food  becomes  necessary.  In  tliis  last 
variety  there  is  quite  probably  an  increased  secretion  of  the  gas- 
tric juice  or,  at  least,  of  the  hydrochloric  acid  contained  in  it ; 
and  a  still  greater  excitation  of  this  secretion  will  brmg  about 
an  aggravation  of  the  heartburn  and  sour  belching,  as  well 
as  of  the  pains  in  the  stomach  and  of  the  sour  vomiting.  More- 
over, while  directing  the  neurasthenic  patients  to  eat,  though 
not  as  frequently  nor  as  little  at  a  time,  as  we  advise  patients 
with  gastric  catarrh,  but  still  not  very  much  at  a  time,  so  as 
not  to  overeat,  we  must  bear  in  mind  that  the  neurasthenic 
patients  are  just  the  ones  who  are  liable  to  fall  into  the  other 
extreme  of  not  eating  sufficiently,  of  starving,  and  thus  prolong- 
ing, through  an  msufficiency  in  the  nutrition  of  the  nervous  sys- 
tem, their  neurasthenia.  In  prescribing  the  diet  we  must  also 
consider  the  constipation,  from  which  the  neurasthenic  usually 
suffers,  especially  in  the  beginning  ;  later  on  there  is  superadded 
a  catarrh  of  the  large  intestine  and  there  appear  intermittently 
both  diarrhoea  and  constipation ;  and  to  counteract  the  costive- 
ness  we  must  vary  the  food  and  prescribe,  as  far  as  possible, 
such  food  to  which  the  patient  is  not  habituated  :  for  instance, 
in  patients  who  habitually  drink  tea  and  no  water,  costiveness 
is  frequently  removed  by  drinking  two  to  three  half  glassfuls  of 
water,  one  half  glass  in  the  morning  on  an  empty  stomach  and 
in  the  course  of  the  day,  one  or  two  hours  before  a  meal ;  in 
others  the  same  effect  is  produced  by  replacing  the  morning  tea 
with  weak  coif  ee  with  milk  and  with  chicory ;  in  others  again 
by  the  use  of  raw  milk  or  of  curdled  milk,  but  without  taking 
at  the  same  time  of  any  other  food  and  particularly  of  bread ; 
by  the  employment  of  vegetables,  (as,  for  instance,  a  half  or  a 
full  glass  of  carrot  juice  in  the  morning  on  an  empty  stomach), 
of  berries  and  fruits,  eaten  not  together  with  the  other  food,  but 
taken  on  the  previously  more  or  less  emptied  stomach. 

The  treatment  of  gastric  nervous  dyspepsia  and  constipation 


—  151  — 

begins  naturally  with  the  treatment  of  the  general  neurasthenic 
condition.  Then  the  same  noyi^apotJiecary  agencies  are  applied 
also  to  the  digestive  organs.  For  the  variety  of  dyspepsia  seen 
in  our  patient,  the  above-described  douches  are  suitable  (in  these 
the  douche  on  the  abdomen  is  allowed  to  play  for  a  somewhat 
longer  time  than  on  the  other  portions  of  the  body),  also  ab- 
dondnal  massage,  as  well  as  the  uiduced  and  interrupted  gal- 
vanic current  applied  directly  to  the  abdomen.  In  the  other 
variety  of  nervous  dyspepsia,  accompanied  hy  gastric  pains 
and  acid  vomiting,  these  means  may  tend  to  aggravate  the  mor- 
bid condition,  and  we  therefore  employ  warm  baths,  static  elec- 
tricity ("  the  bath  "  and  the  "  fan  "  to  the  region  of  the  stomach) 
and  the  constant  galvanic  current  (one  electrode  over  the  stom- 
ach, the  other  on  one  or  the  other  side  of  the  neck,  at  the  region 
of  the  vagus  and  the  great  sympathetic  nerves). 

If  with  the  nervous  dyspepsia  there  is  also  abdominal  suffer- 
ing, causing  attacks  of  pain  and  sensitiveness  of  the  affected 
organs  (for  instance,  liver  and  kidney  colic,  acute  or  subacute 
catarrh  of  the  biliary  and  urinary  tracts,  as  well  as  of  the  stom- 
ach and  intestines),  then  only  warm  baths  are  suitable  and 
probably  also  franklinization  ;  douches,  massage,  the  induced  and 
the  interrupted  galvanic  current  will  onl}^  tend  to  aggravate 
the  condition  of  such  patients  (and  at  times  even  to  a  danger- 
ous extent,  as  douches  and  massage  by  causing  hsematuria  and 
acute  exacerbation  of  pyelitis). 

Silver  nitrate  is  apparently  suitable  in  an  equal  degree  to 
either  variety  of  nervous  dyspepsia.  Bitters,  and  particularly 
nux  vomica,  are  beneficial  in  the  variety  of  neurasthenia  seen  in 
our  patient,  but  are  unsuitable  where  there  is  pyrosis  and  severe 
belching,  gastric  pains  and  acid  vomitmg,  as  they  aggravate  these 
symptoms,  evidently  by  creating  a  still  greater  excitation  of  the 
secretion  of  the  gastric  juice  or  at  least  of  its  hydrochloric  acid. 
It  was  thus  in  the  second  case  discussed  by  us  (vide  p.  122). 
In  such  patients,  if  there  be  at  the  same  time  a  gastric  catarrh, 
requiring  the  use  of  an  alkaline  mineral  water,  for  instance  of 
Ems,  this  last  must  be  given  after  a  meal,  say' in  about  an  hour ; 
it  is  then  borne  well  (probably  because  the  secretions  of  the 
gastric  juice  caused  by  it  is  used  up  for  digestion),  whereas,  if 


_.  152  — 

given  one  hour  before  a  meal  it  tends  to  call  out  pyrosis,  acid 
belching  and  even  pain  in  the  stomach. 

At  times  the  constipation  is  rapidly  put  a  stop  to  by  the  radi- 
cal, above-outlined  method  of  treating  general  and  gastro-intesti- 
nal  neurasthenia ;  but  at  other  times  it  is  slow  in  disappearing 
and  we  then  must  resort  to  temporary  means,  to  clysters,  and, 
much  less  frequently,  to  laxatives  ;  but  we  first  of  all  insist  upon, 
that  the  patient  respond  promptly  to  the  inclmation  to  stool.  I 
have  spoken  elsewhere  of  the  prmoipal  mdications  for  the 
regular  employment  of  clysters.  I  will  add  here,  that  it  is 
usually  sufficient  to  make  a  clyster  of  two  to  three  glasses  of 
water  of  the  temperature  of  20°i?.  (about  79°i^.).  The  best 
time  to  employ  a  clyster  is  in  the  morning,  after  the  first  meal 
(especially  after  the  coffee)  and  before  beginnmg  one's  usual  work, 
which  may  weaken  the  already  lessened  mclination  to  stool. 
Havmg  put  in  the  clyster,  some  would  do  better  to  at  once  re- 
spond to  the  consequent  inclmation  to  stool,  while  for  others  it 
is  better  to  resist  for  a  few  minutes  :  experience  will  teach  in 
which  case  one  or  the  other  advice  is  more  beneficial.  The  ap- 
prehension to  become  habituated  to  clysters  is  without  any 
ground,  if  we  employ  at  the  same  time  all  the  therapeutic  and 
hygienic  measures  for  curmg  the  general  and  the  gastro-mtestinal 
neurasthenia. 

In  case  the  clysters  do  not  sufficiently  empty  the  intestines, 
then,  until  the  radical  treatment  of  the  constipation  has  not  done 
its  work  completely,  resort  must  be  had  to  the  employment  of 
laxatives.  In  view  of  the  great  number  of  laxatives  recom- 
mended, I  consider  it  necessary  to  enumerate  those  that  have 
proved  themselves  preferable  over  others,  in  my  experience. 
1.  Magnemi  usta  —  burnt  magnesia  —  a  light  laxative.  2,  Po- 
tassium tartrate  —  much  stronger.  3.  Sodium  sulphate  ( Grlau- 
hers  salt),  still  stronger  (it  is  best  to  administer  this  with  the 
addition  of  some  sodium  bicarbonate,  or  in  some  alkaline  mm- 
eral  water,  otherwise  it  may  cause  intestinal  pains  and  unneces- 
sary looseness  of  the  bowels.  4.  Poivdered  rhubarb  — either  by 
itself  or,  m  case  of  pyrosis,  in  conjmiction  with  half  its  quantity 
of  burnt  magnesia ;  it  acts  moderately,  but  effectually.  5.  Aloe 
is  probably  the  best  laxative  because  of  the  reliability  of  its  action. 


—  153  — 

which,  besides,  approaches  normal  laxation ;  nor  does  one  become 
habituated  to  its  use  for  a  long  time ;  (the  best  formula :  5^.  — 
Extr.  Rhei  comp.,  extr.  aloes  aa.  3ss.  M.  f.  1.  a.  pilulse  20  v.  30. 
Consp.  lycopodio).  6.  Folia  sennae  —  acts  well  and  not  strongly 
in  a  cold  infusion  (when  hot  will  rather  tend  to  cause  pain), 
which  is  readily  prepared  at  home.  7.  Infusum  sennae  salinum 
(i.  e.,  with  the  addition  of  Glauber's  salt)  is  a  strongly  acting- 
laxative,  especially  suitable  when  a  sure  and  rapid  effect  is 
desired,  as,  for  instance,  in  cases  of  dangerous  cerebral  attacks 
(congestion  of  the  brain  threatening  apoplexy):  it  is  then  given 
every  hour  in  wineglassful  doses  (contammg  two  tablespoon- 
fuls),  till  the  desired  effect  is  obtamed.  8.  Podoioliyllin^  9.  Gas- 
car  a  sagrada^  and  10.  Cortex  rliamnifraugulae  are  all  very  useful,  if 
it  become  necessary  to  temporarily  replace  the  rhubarb,  aloe  and 
the  semia  leaves,  to  which  the  patient  became  habituated,  and 
which  have  therefore  ceased  to  be  effective.  11.  Calomel ;  this 
is  probably  borne  by  the  gastro-intestmal  organs  better  than  all 
the  other  laxatives,  and  is  particularly  suitable  in  diseases  of 
the  biliary  passages  and  in  acute  mfectious  diseases  of  the  mtes- 
tinal  canal,  but  it  has  also  its  contra-indications.  (This  will  be 
spoken  of  in  another  lecture.)  12.  Castor-oil  acts  effectively, 
but  is  unsuitable  for  frequent  use.  The  doses  of  the  laxa- 
tive remedies  are  approximately  given  by  pharmacology : 
each  given  case  must  be  individualized,  beginning,  in  case  there 
are  no  urgently  necessary  indications,  with  a  small  dose. 

To  judge  by  the  course  of  his  health,  it  will  not  be  necessary 
to  employ  the  clysters  m  our  patient  for  a  long  time,  nor  will 
there  hardly  be  any  urgency  for  the  administration  of  laxatives ; 
but  there  occur  cases,  usually  in  elderly  persons  whose  muscular 
apparatus  is  not  only  in  a  condition  of  asthenia,  but  already  in 
that  of  atrophy,  where  there  are  found  at  one  and  the  same 
time  morbid  conditions  of  the  abdominal  and  thoracic  organs 
absolutely  contra-indicating  the  employment  of  hydrotherapy, 
massage,  and  of  the  induced  and  interrupted  galvanic  currents, 
and  where  the  exhaustion  of  the  patient  constitutes  an  obstacle 
m  the  way  of  applymg  correct  hygiene,  as,  for  mstance,  sufficient 
exercise ;  m  such  cases  the  business  of  the  physician  consists 
.wholly  in  the  skilful  contemporaneous  employment  of  clysters 


—  154  — 

and  of  laxatives,  in  the  dexterous  selection  and  careful  inter- 
changing of  these  last. 

In  our  first  analyzed  case  we  had  to  treat  diarrhoea,  in  the 
present  case,  constipation ;  either  of  the  patients  have,  com- 
paratively speaking,  simple  cases  of  diarrhoea  and  constipation. 
Quite  different  is,  of  course,  the  treatment  of  constipation,  that 
intermits  with  a  diarrhoea,  in  cases  of  intestinal  neurasthenia 
with,  at  the  same  time,  a  chronic,  obstinate  catarrh  of  the  large 
intestme ;  this  presents  a  wide  field  for  the  systematic  employ- 
ment of  clysters,  simply  evacuatmg  and  medicated  ones  —  with 
tannin,  bismuth,  boric  acid,  etc. ;  different  also  is  the  treatment 
of  diarrhoea  in  acute  and  chronic  infectious  diseases  of  the  intes- 
tinal canal,  in  stagnation  of  blood  in  the  portal  vein  because  of 
hepatic  diseases,  m  the  various  neuroses,  as  in  Basedow's  dis- 
ease ;  different  is  the  treatment  of  constipation,  if  along  with  it 
there  are  found  other  morbid  conditions,  thoracic,  abdominal  and 
cerebral. 

The  general  question  :  "  how  to  treat  constipation,"  or  "  how 
to  treat  diarrhoea  "  is  just  as  unreasonable  as  the  question  "  how 
to  treat  a  cough " :  in  each  given  case  the  ordermg  of  treat- 
ment must  be  preceded  by  a  precise  diagnosis. 

We  will  now  turn  to  our  patient,  who  is  leavmg  the  clinic  to- 
day, intending  to  go  to  his  home. 

For  the  eleven  days  which  passed  smce  we  saw  the  patient 
the  last  time,  he  took  bitters  and  silver  nitrate  in  pills  (one- 
twentieth  grain  twice  a  day),  when  necessary  he  had  watery 
clysters  and  the  daily  employment  of  the  fan-like  douche  under 
high  pressure,  in  the  beginnmg  at  20°i?.,  the  last  days  at  18°^.; 
on  the  abdomen  the  douche  played  somewhat  longer  than  on 
the  other  parts  of  the  body.  The  patient  bore  the  douches  very 
well :  he  rapidly  warmed  himself  and  felt  heartier  after  the 
douche.  For  this  period  we  had  to  resort  to  the  bromides  four 
times  (fifteen  grams  at  bedtime)  :  he  slept  sounder  after  this. 

Status.  —  The  patient,  as  you  hear,  declares  hunself  much 
better  than  what  he  was  formerly  ;  the  appetite  is  good,  the  dys- 
peptic gastric  phenomena  disappeared,  the  stool  is  mostly  regu- 
lar, the  clyster  is  used  only  at  times,  the  former  painful  sensations 
in  the  abdomen  passed  away ;  the  former  cardiac  attacks  hardly 


—  155  — 

at  all  trouble  him  now ;  the  physical  strength  is  good  (patient 
began  taking  out-door  walks),  but  the  sleep  is  not  always 
sound,  while  mental  occupation  still  causes  headache,  although 
not  a  severe  one,  and  a  feeling  of  fatigue. 

On  the  morning  of  the  day  before  yesterday,  the  patient, 
while  rising  awkwardly  from  his  bed,  felt  a  sudden  pain  in  the 
right  inguinal  region.  The  cause  of  the  pain  was  shown  by 
mvestigation  to  be  due  to  a  slightly  displaced  kidney ;  after  this 
was  pushed  back  into  its  place,  the  pain  disappeared.  There  is 
no  doubt  but  that  the  kidney  was  movable  before  (before  the 
appearance  of  pain  the  patient  did  nothing  that  could  displace 
and  make  movable  a  kidney  that  was  until  now  normally  im- 
planted in  its  place),  but  it  was  supported  in  its  place  by  the 
intestines,  which,  on  account  of  the  constant  constij)ation,  were 
considerably  distended  with  gases.  At  present,  when  with  the 
regular  evacuation  of  the  bowels,  the  meteorism  passed  away 
(the  abdomen  is  not  distended),  a  trifling  cause,  such  as  an 
awkward  movement,  was  sufficient  to  displace  the  now  mov- 
able kidney.  However,  the  displacement  is  not  great  and  it 
is  quite  likely  that  he  will  be  able  to  get  along  without  a  kid- 
ney truss,  and  a  belt  worn  either  separately  or  attached  to  the 
mider-dress  may  suffice.  While  movmg  about,  the  patient  will 
have  to  tighten  the  belt,  and  when  at  rest  to  loosen  it,  otherwise 
the  constant  tightening  of  the  part  of  the  abdomen  under  the 
belt  will  aggravate  the  constipation. 

Our  advice  to  the  patient :  after  leavmg  the  cluiic  to  take 
silver  nitrate  (it  apparently  does  not  increase  the  constipation 
in  our  patient)  for  another  month,  gradually  mcreasing  the 
dose  (the  first  two  weeks  three  pills  daily,  the  next  two,  four 
a  day,  while  the  last  days  to  reduce  by  one  pill  daily)  and 
then  continue  for  another  six  weeks  the  fan-like  douche  from  a 
hand-pump,  gradually  lowering  the  temperature  to  16°it. ;  to 
resort  to  potassium  bromide  as  rarely  as  possible,  and  when 
necessary  to  use  a  clyster. 

We  have  spoken  already  of  the  hygienic  mstructions. 


FOURTH  CASE, 


FROM  THE  LECTURE  OF  NOVEMBER  24, 

The  patient,  of  whom  we  will  speak  presently,  since  his 
admission  to  our  clmic  was  so  exhausted  and  suffered  from 
such  torturing  pains,  that  we  could  hardly  think  of  transfer- 
ring him  from  his  ward  to  the  class-room  for  demonstration. 
However,  not  only  were  all  the  hospital  attendants  well  informed 
about  his  condition  and  our  views  concerning  it,  but  almost  all 
of  you,  while  visiting  the  ward,  had  the  opportunity  to  see 
everything  that  could  possibly  be  demonstrated  before  a  large 
audience :  chiefly  the  emaciated  and  cachectic  appearance  of  the 
patient  and  the  attacks  of  tormentmg  vomiting,  from  which  he 
suffered ;  therefore  in  view  of  the  interest  m  the  case  I  will  take 
it  up  now. 

The  patient,  a  retired  military  man,  fifty-nme  years  old,  was 
admitted  to  our  clinic  complaining  of  oppressive  pain  in  the 
stomach,  pyrosis,  belchmg  of  the  odor  of  rotten  eggs,  of  vomitmg 
and  constant,  tormenting  nausea  (which  compelled  him  at  times 
to  induce  vomiting  by  irritating  the  pharynx  by  tickling),  and 
also  of  emaciation  and  debility. 

AnamneBis  and  mode  of  living.  —  Since  his  youth  patient  has 
lived  almost  his  whole  life  m  the  Caucasus,  where  he  frequent- 
ly suffered  from  malaria,  for  which  he  was  treated  with  quinine. 
For  the  last  ten  years  patient  was  always  subject  to  costiveness, 
and  he  frequently  experienced  after  a  meal  slight  heaviness  in 
the  stomach  and  belchmg,  that  annoyed  him  but  little.  For  the 
rest,  luitil  last  summer  (1889),  our  patient,  bemg  of  strong  con- 
stitution and  leading  a  quiet  life  under  favorable  conditions, 
could  hardly  complain  of  anything.  The  chief  irregularity  in 
his  mode  of  living  consisted  m  a  lack  of  exercise,  constant 
sittmg,  while  reading,  writing  or  at  times  playing  cards,  in  a 


—  157  — 

very  plentiful  table  and  considerable  use  of  alcohol  —  two  to 
three  wine-glasses  of  whiskey  daily,  about  two  glasses  of  .local 
Caucasian  wine  and  tea  with  cognac.  Durmg  June  the  pa- 
tient passed  through  the  customary  attack  of  malaria,  which 
quickly  yielded  to  quinine,  but  after  this  the  usual  gastric 
symptoms,  heaviness  and  belching  after  meals,  became  aggra- 
vated and  were  accompanied  by  others  —  pjTosis  and  nausea  ; 
the  constipation  became  more  obstinate.  Until  the  middle 
of  August  the  patient's  condition  was  bearable  enough  and  he 
did  not  resort  to  treatment.  But  since  then  the  condition  be- 
came rapidly  aggravated :  the  appetite  disappeared,  the  sensation 
of  heaviness  in  the  stomach  gave  way  to  oppressive  pain,  belch- 
ing (now  malodorous,  of  rotten  eggs)  and  pyrosis  increased; 
patient  began  to  vomit,  the  nausea  became  a  torture,  and  the 
patient  was  compelled  to  intentionally  provoke  vomiting ;  he 
grew  thin  and  weak.  He  then  called  in  his  physician.  The 
treatment  (at  first  HCl,  later  the  bitters,  condurango  and  nux 
vomica,  and  Vichy  water  m  one-half  glassful  doses  tlrree  times 
a  day,  then  gastric  lavage)  brought  but  little  relief  and  for  a  short 
time :  the  gastric  symptoms  kept  on  growing  worse,  while  his 
nutrition  and  strength  failed  with  ever  increasing  rapidity,  till 
in  this  condition  he  was  admitted  into  our  clinic. 

The  clinical  investigation  elicited  the  following.  The  ner- 
vous system  in  a  normal  condition  (inquiry  has  failed  to  estab- 
lish the  existence  at  any  time  even  of  neurasthenia);  and  so  are 
the  organs  of  respiration.  There  are  signs  of  arterio-sclerosis ;  the 
arteries  are  somewhat  hard ;  there  is  a  slight  systolic  mui'mur  over 
the  sternum  and  a  moderate  enlargement  of  the  left  ventricle  :  the 
heartbeat  is  felt  the  clearest  in  the  mammillary  line ;  the  pulse  is 
frequent  and  somewhat  weak ;  the  temperature  of  the  body  is 
subnormal,  and  there  is  extreme  emaciation.  The  urine  con- 
tams  some  sugar  (one  per  cent)  and  some  albumen.  The  inquiry 
failed  to  elicit  any  clearly  pronounced  sj^mptoms  of  diabetes 
mellitus,  as  immoderate  thirst  and  appetite,  m  the  past.  By 
objective  examination  nothing  abnormal  is  to  be  noted  in  the 
liver,  spleen  and  kidneys.     Patient  had  no  syphilis. 

The  digestive  organs.  —  All  the  above  enumerated  symptoms, 
that  progressively  increased  before  the  patient's  admission  to  the 


—  158  — 

clinic,  continued  to  augment  rapidly,  accompanied  by  a  corre- 
sponding failing  of  the  strength ;  almost  from  the  very  first  day 
the  patient  failed  to  retain  the  administered  trifimg  quantity  of 
food  and  of  medicme,  the  latter  consisting  of  some  Ems  water 
and  condurango,  tra.  valer.  eether.,  and  morphine.  The  food 
was  ejected  completely  undigested.  The  ejecta,  as  proved  by 
repeated  exammation,  contained,  besides  the  undigested  food, 
very  little  mucus,  very  little  hydrochloric  acid  (0.33  per  1,000) 
and  usually  some  bile ;  there  was  never  an}^  blood.  The  sub- 
gastric  region  was  slightly  distended  and  somewhat  sensitive  ; 
no  swelling  in  the  abdomen  could  anywhere  be  palpated.  Gas- 
tric lavage  done  the  very  first  day  with  a  solution  of  soda, 
brought  but  a  trifling  relief  from  the  gastric  symptoms,  while 
lavage  on  the  next  day  failed  even  in  this.  The  clyster  brought 
away  a  small  quantity  of  dry  excreta. 

In  speaking  of  the  diagnosis,  I  will  take  up  only  the  organs 
of  digestion;  on  the  others  I  will  touch  but  lightly.  The  im- 
portance of  abnormal  phenomena  in  the  organs  of  circulation 
was  already  alluded  to.  The  constant  presence  of  albumen  in 
the  urine  (although  cylinders  are  absent)  depends,  most  likely, 
on  the  presence  of  a  slight,  so-called  senile^  interstitial  nephritis, 
that  usually  accompanies  arterio-sclerosis  in  aged  people. 
The  failure  in  nutrition  and  strength  must  certainly  be  consid- 
ered as  a  result  of  the  disease  of  the  digestive  organs,  and  not 
of  diabetes,  which  never  presented  any  pronounced  symptoms, 
while  the  percentage  of  sugar  was  trifling.  We  will  have  time 
to  discuss  m  detail  the  importance  of  the  symptoms  and  diagnosis 
of  arterio-sclerosis,  as  well  as  of  the  nephrites  and  of  diabetes 
mellitus  later  on  in  suitable  cases,  m  which  these  diseases  play 
the  chief  role. 

What  disease  of  the  digestive  organs  is  our  patient  suffermg 
from  ?  It  is  evident  from  the  first  that  it  is  a  disease  of  the 
stomach.  Which  is  it  ?  Nervous  dyspepsia  can  surely  be  ex- 
cluded ;  not  to  speak  of  the  fact,  that  nervous  dyspepsia  can 
hardly  ever  bring  one  to  the  condition  in  which  we  find  our  pa- 
tient, there  is  nothmg  that  would  speak  for  it :  neither  did  the 
patient  ever  suffer  from  general  neurasthenia,  nor  do  the  gastric 
symptoms  present  the  important  feature  of  nervous  dyspepsia. 


—  159  — 

namely,  changeability ;  on  the  contrary,  they  are  very  con- 
stant. 

Does  our  patient  have  an  ordinary  gastric  catarrh  ?  To  cause 
the  gastric  symptoms  to  the  degree  seen  in  our  patient,  the 
catarrhal  condition  should  have  been  extremely  developed,  con- 
sequently there  would  have  been  a  great  accumulation  of  mu- 
cus, whereas,  on  the  contrary,  there  is  very  little  of  it. 

Grastric  ulcer  may  evidently  also  be  excluded,  as  there  are  no 
attacks  of  acute  pain  so  peculiar  to  this  condition  (cardialgia), 
nor  was  there  any  blood  m  the  vomited  matter. 

Our  patient  has,  first  of  all,  atrophic  gastric  catarrh,  an 
atrophy  of  the  gastric  glands ;  this  is  apparent  from  the  fact, 
that  the  vomited  food  is  undigested  and  the  quantity  of  hydro- 
chloric acid  is  very  much  diminished  (0.33  per  1,000  instead 
of  the  normal  2.00  per  1,000).  But  atrophic  catarrh  of  the 
stomach  is  observed  in  various  diseases,  which  lead  to  exhaus- 
tion, to  marasmus  of  the  organism.  Which  of  these  diseases  is 
the  most  probable  in  this  case  ?  It  is  cancer,  because  the  pa- 
tient, who  only  four  or  five  months  ago  enjoyed  his  ordinary, 
for  the  last  ten  years,  good  health  and  even  a  florid  nutrition, 
was  reduced  m  such  a  short  time  to  extreme  marasmus ;  of 
chronic  diseases,  leading  to  marasmus,  it  is  the  malignant 
growths  which  have  a  particular  tendency  to  such  a  rapid  course. 
The  absence  of  signs  of  other  chronic  diseases,  that  may  bring 
about  a  condition  of  marasmus  (as,  for  instance,  inveterate 
syphilis  or  tuberculosis,  etc.),  as  well  as  the  patient's  age,  also 
speak  for  cancer.  The  localization  of  this,  in  view  of  the  obsti- 
nate vomiting,  is  most  likely  to  be  in  the  pylorus  of  the  stomach 
(no  swelling  is  anywhere  to  be  palpated),  although  the  almost 
constant  presence  of  bile  in  the  vomited  matter  speaks  some- 
what against  a  difficult  passage  in  this  place.  Cancer  pan- 
creatis  is  to  be  excluded  to  some  extent  by  the  absence  of 
permanent  jaundice,  which  could  be  expected  in  a  cancer  of 
this  organ,  of  sufficient  size  to  compress  the  duodenum,  on  ac- 
count of  the  pressure  exerted  by  the  cancerous  growth  on  the 
ductus  choledochus  (not  to  mention  the  possible  ascites  from 
pressure  of  the  same  swelling  on  the  vena  portse).  We  are 
generally  unable  to  obtam  am^  definite  symptoms  of  a  pancre- 


—  160  — 

atic  cancer,  that  would  result  from  the  mfluences  created  by  a 
cessation  of  the  functional  activity  of  this  organ,  nor  can  we 
certamly  do  so  in  the  present  case,  as  everything  mtrocluced 
into  the  stomach  is  vomited  up. 

The  treatment,  in  view  of  the  impossibility  of  introducmg  any- 
thmg  mto  the  stomach  and  of  the  rapidl}^  approaching  dissolu- 
tion, could  only  consist  of  nutritive  enemata  (two  to  three  raw 
eggs  with  the  addition  of  some  water  and  table  salt,  the  whole 
contained  in  a  glass  and  warmed  to  the  temperature  of  30°i2.), 
to  which  were  added  some  eight  drops  of  laudanum,  so  that  the 
clyster  could  be  better  retained,  and  a  dessertspoonful  of  cognac 
as  a  stimulant ;  for  the  excruciatmgly  pamful  vomiting  we  some- 
times mjected  morphine  hypodermically  (one-eighth  grain  at  a 
time). 

Patient  died  on  the  thirteenth  day  after  his  admission  to  the 
clinic.  Autojjsy  showed :  sclerosis  of  the  arteries,  among  others 
also  of  the  aorta ;  left  ventricle  dilated,  its  walls  pale  and 
flabby,  but  presenting  at  some  places  traces  of  hypertrophy ;  a 
moderate  nephritis,  the  liver,  spleen  and  pancreas  present 
no  changes ;  catarrh  and  atrophy  of  almost  the  whole  mucous 
membrane  of  the  stomach  (it  is  very  much  thinned  out  and 
is  perfectly  smooth,  its  surface  not  presenting  that  normal 
mammillary  appearance,  surface  mamelonnee^,  the  muscular 
layer  of  the  stomach  is  also  atrophied ;  the  duodenum  is  so  con- 
stricted in  its  lower  third,  that  it  hardly  admits  an  ordinary 
pencil :  on  the  inner  surface  of  the  posterior  wall  of  the  mtestme 
in  this  locality  there  is  a  cancerous  ulcer  the  size  of  a  ten  cent 
piece  —  situated  in  the  cancerous  growth  of  the  intestinal  wall, 
this  last  —  the  tumor  —  being  the  size  of  a  walnut ;  the  neigh- 
boring mesenteric  glands  present  a  series  of  cancerous  me- 
tastases. 


Thus  m  the  four  patients  demonstrated  by  me,  you  had  the 
opportunity  to  observe,  besides  a  great  many  other  ailments,  the 
prmcipal  varieties  of  diseases  of  the  stomach,  namely :  pure 
nervous  dyspepsia  (m  the  third  case),  —  a  pure  chronic  gastric 


—  161  — 

catarrh  (in  the  first), — simultaneously  (in  the  second),  chronic 
catarrh,  ulcer  and  gastric  dilatation,  with  additional  phenomena 
of  nervous  dyspepsia,  where,  however,  notwithstandhig-  the 
co-existence  of  several  diseases  of  the  stomach,  it  was  possible  to 
diagnose  each  of  them,  —  and,  finally,  an  atrophic  catarrh  of  the 
stomach,  and  cancer,  if  not  of  the  pylorus,  then  of  the  duo- 
denum, which  is  so  similar  to  it  m  its  symptoms. 


FIFTH  CASE. 


FROM  THE  LECTURE  OF  DECEMBER  7,   1890. 

The  patient,  a  peasant,  fifty  years  old,  was  admitted  to  the 
clinic  November  24th,  complaining  of  pain  in  the  epigastric 
region  and  in  the  right  hypochondrium,  of  jaundice,  emaciation 
and  general  weakness. 

Anamnesis  and  mode  of  living.  —  Until  his  twentieth  year  pa- 
tient lived  in  a  village,  since  then  in  Moscow,  in  the  capacity 
of  a  janitor.  His  lodgings  are  fair.  He  bathes  himself  during 
summer  in  the  sea,  at  other  seasons  of  the  year  takes  his  bath  — 
a  sweat  bath  —  every  week.  Drinks  a  great  deal  of  hot  tea,  a 
moderate  quantity  of  whiskey  during  the  last  year,  but  used  to 
drink  to  excess  formerly.  His  food  is  the  ordinary  food  of  a 
workingman.  Until  the  appearance  of  the  disease  he  did  not 
fi^nd  his  occupation  fatiguing.  Is  married  and  has  many 
children. 

When  nine  years  old,  patient  passed  through  an  attack  of  va- 
riola; when  twenty-one  years  he  had  some  febrile  disease  from 
which  he  completely  recovered,  enjoying  good  health  since  and 
until  last  August.  Patient  had  no  syphilis.  Last  May  patient 
had  a  severe  affliction.  Last  August  there  appeared  some  pains 
in  the  epigastric  region  and  in  the  right  hypochondrium,  the 
appetite  became  impaired,  and  he  grew  costive.  Three  weeks 
ago  —  in  the  beginning  of  November  —  there  appeared  jaundice 
and  the  patient  grew  markedly  emaciated  and  weak.  While  in 
the  clinic  he  continued  costive  (every  one  or  two  days  he  had 
some  dry  excreta,  not  in  the  least  colored  by  bile),  and  the  abdo- 
men was  somewhat  distended.  Patient  was  given,  November 
30th,  seven  powders  of  calomel,  each  containing  one  grain  (the 
first  five  every  hour,  the  last  two  every  two  hours)  :  the  stools 
were  a  little  loose,  and  only  slightly  colored  by  bile,  but  they 


—  163  — 

were  not  the  characteristic  calomel  stools ;  patient  was  not 
weakened  after  this,  but  neither  did  he  experience  any  relief 
(the  pains  remained  as  heretofore).  Besides  calomel  the  patient 
took  daily  (except  November  30th)  three  half-glassfuls  of  warm 
Ems  water,  once  or  twice  (during  the  exacerbation  of  the  pains) 
one-quarter  grain  of  codeine,  and  during  the  day  some  four 
tablespoonfuls  of  strong  wine  (the  pulse  was  all  the  time  some- 
what weak).  As  the  evening  temperature  rose  to  38.5°  (101.3° 
^.),  he  was  sometimes  given  quinine  (five  grains  per  dose  once 
a  day)  ;  this  apparently  diminished  the  febrile  condition.  Be- 
sides, he  had  some  warm  baths,  that  tended  to  relieve  somewhat 
the  pains  and  the  itching  of  the  skin. 

Status.  —  The  patient  is  of  good  constitution,  but  very  emaci- 
ated ;  the  skin  and  the  sclerotics  are  severely  jaundiced.  The 
appetite  is  very  poor.  There  are  almost  no  dyspeptic  phenom- 
ena, except  some  slight  heaviness  after  a  meal :  he  never  had,  nor 
has  he  now  any  constant  and  painful  belching,  pyrosis,  nausea 
or  vomiting.  The  pains  in  the  epigastric  region  and  in  the  right 
hypochondrium  do  not  become  aggravated  after  a  meal,  but  do 
so  on  pressure  on  the  painful  parts.  The  abdomen  is  dis- 
tended. The  liver  is  enlarged  and  sensitive  to  pressure,  but 
does  not  present  any  palpable  unevenness  or  any  protuberance ; 
the  gall-bladder  is  distended  to  the  size  of  a  considerable  swel- 
ling, but  is  almost  insensitive  to  pressure.  The  spleen  is  some- 
what enlarged.  Patient  is  constipated  :  after  the  calomel  he 
had  every  other  day  watery  clysters,  which  brought  away  a 
small  quantity  of  uncolored  by  bile  evacuations.  The  urine  is 
very  much  jaundiced,  contains  neither  sugar  nor  albumen.  The 
arteries  are  slightly  stiff,  the  pulse  is  frequent  and  somewhat 
weak.  The  organs  of  respiration  present  nothing  abnormal. 
Patient,  as  I  said  once,  is  feverish ;  his  evening  temperature 
ranges  between  37.5°i^,  (99,5°i^,)  and  38,5°i^,  (101,3°^,),  His 
sleep  is  poor,  he  is  at  times  dizzy ;  his  skin  itches. 

Diagnosis.  —  A  morbid  process,  which  develops  in  a  man  no 
longer  young,  approaching  old  age,  but  of  strong  constitution 
and  good  health  heretofore,  —  especially  if  developed  after  a 
severe  affliction,  —  and  leading  the  patient  to  a  rapid  failure  of 
nutrition  and  of  strength,  is  usually  a  cancer  (generally  a  malig- 


—   164  — 

nant  new  formation),  less  frequentl}'  diabetes  mellitus.  Our 
patient  has  neither  diabetes  nor  any  other  pathological  process 
(except  a  cancer)  which  could  explain  his  dangerous  condition. 
Syphilitic  gumma,  compressing  the  ductus  choledochus,  is  most 
certainly  out  of  the  question  :  not  only  does  the  patient  deny 
infection,  but  he  presents  absolutely  no  signs  of  syphilis  (besides, 
his  wife  had  eleven  children  and  not  a  single  abortion).  Hy- 
pertrophic biliary  cirrosis  and  multilocular  echmococcus  of  the 
liver,  which  one  may  be  led  to  suspect  in  view  of  the  enlarge- 
ment of  the  liver  and  because  of  the  jaundice,  are  to  be  excluded, 
besides  other  considerations,  by  their  much  slower  courses ;  so 
that  only  cancer  remains.  Which  organ  is  affected  by  it?  It 
is  evidently  not  the  stomach,  because  there  are  neither  severe, 
nor  in  fact  any  gastric  symptoms,  and  besides  it  is  apparent, 
that  the  ductus  choledochus  is  compressed  (the  evacuations  are 
not  in  the  least  colored  by  bile,  there  is  jaundice,  the  gall-blad- 
der is  very  much  distended),  and  consequently  the  tumor  must 
be  located  about  it.  It  is  evident  that  the  tumor  is  most  likely 
to  be  assumed  as  lying  on  the  lower  surface  of  the  liver  (in  the 
porta  hepatis),  or  that  it  is  a  cancer  of  the  pancreas.  We  have 
already  stated  in  connection  with  the  previous  case  that  we 
have  no  reliable  symptoms,  outside  of  a  localized  swellmg,  that 
would  indicate  a  cancer  of  the  pancreas,  nor  can  we  detect  any 
such  swellmg  in  our  patient.  Cancer  of  the  liver  is  to  be  ex- 
cluded —  though  not  absolutely  so  —  by  the  fact  that  m  the 
part  of  the  liver  accessible  to  palpation  there  is  observed  neither 
any  unevenness,  nor  any  protuberance,  and  besides,  its  sensitive- 
ness is  not  great  and  is  everywhere  equable,  and  not  severer  in 
some  places  than  in  others.  This  sensitiveness  and  at  the  same 
time  the  enlargement  of  the  liver  is  fully  explamed  by  the  stag- 
nation of  the  bile  in.  this  organ  and  the  consequent  distention 
of  its  capsule. 

Prognosis  —  is  but  too  evident. 

Treatment.  — -  Notwithstanding  the  improbability  of  the  pres- 
ence of  such  a  process  in  the  biliary  tract  in  our  patient,  on 
which  treatment  could  produce  an  effect,  we  nevertheless  at- 
tempted in  the  beginning  to  treat  the  case  by  calomel  and  Ems, 
but  failed  to  obtain  any  results.     It  only  remains  now  to  sus- 


165 


tain  the  patient's  strength  and  relieve  the  particular!}^  painful 
symptoms  ;  the  means  for  this  were  spoken  of  before. 


FROM  THE  LECTURE  OF  JANUARY   18,  I89I. 

The  condition  of  the  patient  grew  continually  worse  and 
January  16th  he  died ;  the  last  two  days  of  his  life  were  marked 
by  a  surprismg  lowermg  of  the  pulse  and  strength,  and  by  ex- 
treme paleness. 

The  autopsy  made  to-day  showed  the  f olloAving :  cancer  of  the 
pancreas,  that  extended  by  ulceration  into  the  duodenum  and 
caused  a  severe  haemorrhage  ;  the  intestines  (except  the  sigmoid 
flexure  and  the  rectum)  are  filled  with  clots  of  blood  ;  the  ductus 
choledochus  is  very  much  distended  above  the  seat  of  pressure, 
and  so  are  all  the  other  biliary  ducts,  as  well  as  the  gall-bladder 
(this  last  to  the  size  of  an  ostrich  egg^. 


SIXTH  CASE. 


LECTURE  OF  OCTOBER  25,   1889. 

The  patient,  a  peasant,  twenty-nine  years  old,  was  admitted 
to  the  clinic  October  20th,  complaining  of  jaundice,  weakness 
and  pains  all  over  the  abdomen,  but  particularly  in  the  right 
hypochondrium ;  he  claims,  that  he  took  sick  one  week  before  his 
admission  here. 

Anamnesis  and  mode  of  living.  —  Patient  comes  from  a  healthy 
family ;  until  his  twentieth  year  he  lived  m  a  village,  then 
served  in  the  militia,  and  for  the  last  two  years,  as  a  member  of 
the  reserve  army,  he  made  Moscow  his  place  of  residence.  His 
lodgmgs  are  fair;  the  water-closet  cold.  While  m  Moscow,  he 
does  not  bathe  in  the  river  (bathed  formerly  and  felt  very 
good)  ;  goes  frequently  to  the  public  bath-house ;  drinks  a  great 
deal  of  hot  tea ;  is  subject  to  sweating.  Twice  a  week  drinks  some 
three  wineglassfuls  of  whiskey.  Order  of  his  meals  :  in  the  morn- 
ing tea  with  bread,  later  dinner,  and  supper.  His  board  is  good 
(fish  on  fast  days),  but  patient  is  very  much  occupied — he 
supervises  the  forwarding  of  goods  and  accompanies  the  wagons 
packed  with  them  —  so  that  he  frequently  takes  his  dinner  not 
at  home,  nor  m  time,  eating  whatever  he  may  get  hold  of  (as 
sausages,  salted  fish,  etc.)  ;  nor  does  he  sleep  enough  on  account 
of  his  occupations.  For  the  last  two  years  patient  had  a  great 
deal  of  worr}^  partly  on  account  of  the  very  responsible  nature 
of  his  occupation,  partly  on  account  of  some  family  troubles. 
Patient  is  single,  had  no  venereal  affections. 

With  such  data  on  hand,  we  certainly  could  not  rely  on  the 
patient's  statement,  m  reply  to  the  first  question,  that  until  the 
present  illness  he  had  never  been  sick.  As  a  matter  of  fact, 
the  inquiry  about  the  patient's  condition,  about  the  functional 
activities  of  his  organism  immediately  before  the  present  illness. 


—  167  — 

has  elicited  the  fact,  that  although  his  appetite,  digestion,  urm- 
ation,  respiration  and  circulation  were  perfectly  normal,  still  the 
patient  while  residing  in  Moscow,  in  better  rooms  and  eating 
better  food  than  formerly,  lost  flesh  and  his  hale  and  hearty 
mental  state,  became  impressionable  and  irritable  ("began  to 
take  things  too  seriously  to  heart ")  ;  besides,  since  October  1st, 
or  some  two  weeks  previous  to  the  present  illness,  he  began  to 
experience,  most  frequently  while  riding  on  the  street  pavement 
(as  he  often  rode  in  a  wagon  while  forwarding  the  goods),  some 
pain  in  the  right  hypochondrium  (patient  pointed  directly  to 
the  region  of  the  gall-bladder). 

October  the  13th  patient  had  eaten  some  fat  soup  of  the  flesh 
of  white  sturgeon,  and  the  same  day,  having  remained  for  a 
long  time  out  of  doors,  he  became  verj-  much  chilled;  in  the 
evening  he  felt  pain  at  the  pit  of  the  stomach  and  weakness. 
The  next  day  the  pain  grew  worse,  and  the  appetite  tecame  im- 
paired ;  on  the  third  day  the  white  of  the  eyes  became  yellow. 
October  16th  patient  took  some  very  salt  and  fat  cabbage 
soup  made  of  kidney,  and  after  this  drank  some  cold  beer. 
There  appeared  on  the  same  day  severe  pains  around  the 
umbilicus  and  an  attack  of  diarrhoea,  which  continued  into 
the  next  day.  October  18th  the  pains  around  the  umbilicus 
diminished  and  the  diarrhoea  ceased,  but  the  pains  in  the 
right  hypochondrium  grew  worse  and  the  urine  became  dark. 
October  20th  the  patient  entered  our  clinic.  For  the  last 
few  days  the  patient  excreted  daily  small  quantities  of  dry 
fetid  evacuations  entirely  uncolored  b}^  bile. 

October  21st  the  patient  was  given  seven  grains  of  calomel 
(in  powder,  one  grain  every  hour)  :  patient  had  good  loose 
stools  the  21st  and  the  2  2d,  copious  and  characteristic 
calomel  dark-green  evacuations,  after  which  the  pains  around 
umbilicus  completely  disappeared,  and  those  in  the  right 
hjrpochondrium  were  relieved,  the  urine  became  clearer,  the 
heaviness  in  the  head  was  relieved,  and  the  appetite  returned. 
The  23d  the  patient  was  given  one-half  glass  of  warm  natural 
Karlsbad  water  (Miihlbrunnen  sprmg),  one  hour  before  dinner, 
and  the  2  2d  two  half-glassfuls,  one  an  hour  before  dinner,  the 
other  an  hour  before  supper. 


—  168  — 

Yesterday,  the  24th,  the  patient  had  a  severe  attack  of 
pain,  lasting  from  five  to  seven  p.  M.,  in  the  right  hypochon- 
drium  and  under  the  right  scapula,  and  at  the  same  time  the 
temperature,  which  was  normal  until  then,  rose  to  38.5°  R. 
(101.3°  #.). 

^to^its.  _  The  temperature  is  as  yet  37.6°i2.  (99.7°i^.),  but 
the  patient,  as  you  may  hear,  claims  to  feel  much  better  now 
than  he  did  before  admission.  The  appetite  is  very  good, 
but  he  is  given  as  yet  but  little  to  eat.  Dyspeptic  phenomena 
are  absent ;  a  clyster,  administered  yesterday,  brought  away  a 
sufficient  quantity  of  evacuations  markedly  colored  by  bile. 
The  urine  is  much  more  limpid,  than  it  was  before,  but  ex- 
amination shows,  that  it  contains  still  some  biliary  pigment 
and  the  biliary  acids,  but  neither  albumen  nor  sugar.  The 
abdomen  (protected  smce  his  admission  by  flannel)  is  sensitive 
only  in  the  region  of  the  gall-bladder,  and  is  not  distended. 
The  liver  is  somewhat  enlarged,  the  gall-bladder  does  not 
permit  of  palpation.  Nothing  abnormal  found  in  the  region 
of  the  spleen  and  of  the  kidneys.  The  organs  of  respiration 
and  of  circulation  are  in  a  normal  condition.  Patient's  sleep 
is  generally  better,  than  it  was  before  admission,  but  still  it 
is  not  perfectly  normal,  partly  on  account  of  the  abdominal 
pains,  and  partly  —  in  the  absence  of  these  last  —  simply 
because  of  the  msomnia  caused  by  worrying  about  his  illness. 
We  alluded  in  the  anamnesis  to  the  somewhat  gloomy  and 
irritable  mental  state  of  the  patient. 

Biagiiosis.  —  Outside  the  light  nervous  sjanptoms,  —  of  the 
significance  of  which  we  have  spoken  already  in  connection  with 
the  discussion  of  neurasthenia  in  the  first  and  third  cases,  —  we 
observe  in  the  patient  at  present  only  symptoms  of  an  affection 
of  the  biliary  tract,  namely :  jaundice,  sensitiveness  on  pressure 
and  pains  in  the  region  of  the  gall-bladder,  usually  not  severe, 
but  at  times  very  severe  and  acute,  in  the  form  of  clearly 
definable  attacks.  For  a  week  before  the  patient's  admission 
to  the  clinic  he  suffered  from  gastro-intestinal  disturbances 
(loss  of  appetite,  intestinal  pains  and  diarrhoea),  which  passed 
away  rapidly  in  the  course  of  two  days.  Up  to  that  time  the 
appetite  and  digestion  were  perfectly  normal,  and  after  that  the 


—  169  — 

appetite  returned  quickly,  the  dyspeptic  phenomena  disap- 
peared, the  intestinal  pains  passed  away  and  there  are,  properly 
speaking,  no  intestinal  symptoms :  if  the  patient  is  costive  and 
if  his  evacuations  are  not  bile-colored,  it  is  to  be  ascribed  to 
the  small  quantity  of  food  and  the  damming  back  of  the 
bile ;  that  is,  to  the  affection  of  the  biliary  tracts,  which  proves 
itself  to  be  a  more  obstuiate  morbid  condition,  than  the  rapidly 
disappearing  gastro-intestinal  disturbances.  It  were  therefore 
erroneous  to  consider  the  present  case  as  one  of  a  gastro- 
intestinal catarrh,  that  spread  into  the  biliary  tracts :  the 
above-mentioned  quickly  passing  away  gastro-intestinal  dis- 
turbances could  hardly  originate  from  any  more  or  less  firmly 
established  gastro-intestinal  catarrh ;  while  the  affection  of  the 
biliary  tracts,  I  must  say  again,  proves  itself  to  be  very  firmly 
established.  Besides,  its  symptoms,  as  pains  in  the  region  of 
the  gall-bladder,  appeared  even  two  weeks  previously  to  the 
before  mentioned  gastro-intestinal  disturbances,  at  a  time  when 
both  the  appetite  and  the  digestion  were  as  yet  perfectly 
normal.  It  is  evident  that  the  disease  of  the  biliary  tract 
existed  before  the  appearance  of  the  enumerated  gastro-in- 
testinal disturbances  and  only  became  aggravated  after  them. 

What  disease  then  of  the  biliary  passages  does  our  patient 
suffer  from?  Guided  by  your  knowledge  of  the  special 
pathology  of  the  internal  organs  and  by  what  I  said  of  biliaiy 
calculi  in  connection  with  the  first  case  discussed  by  us,  you 
have  probably  concluded,  by  this  time,  that  our  patient  is  suf- 
fering with  calculi  m  the  gall-bladder,  and  you  are  not  in  error : 
our  patient  is  really  suffering  from  this  disease,  which,  although 
not  completely  developed,  presents,  nevertheless,  all  its  charac- 
teristic symptoms  ;  —  a  disease  of  great  importance,  because  of 
its  frequent  occurrence  and  because  it  is  so  easily  cured  by  a 
correct  treatment  and  regimen  (hygiene),  while  otherwise  it 
may  ruin  one's  health  and  become  dangerous.  I  consider  it, 
therefore,  necessary  to  stop  here  to  discuss  the  importance  of 
its  symptoms,  its  diagnosis  and  therapy. 

What  is  the  formation  of  gall-stones  due  to  ?  All  are  agreed 
on  one  point,  namely,  that  it  is  promoted  by  the  sluggish  pas- 
sage of  the  bile  along  the  biliary  tracts.     This  fact  explains  the 


—  170  — 

frequency  of  biliary  calculi  in  women  (the  wearing  of  a  narrow 
corset  and  pregnancies  limit  the  movements  of  the  diaphragm, 
which  assist  in  propelling  the  bile  along  its  passages  and  its 
entrance  into  the  intestines)  and  in  men  of  sedentary  habits 
of  life  (m  these  also  the  movements  of  the  diaphragm  are 
hmdered,  and  are  neither  as  free,  nor  as  extensive  as  in  men 
leading  a  lively,  physically  active  mode  of  life).  It  was 
further  assumed  that  the  cause  of  the  formation  of  biliary 
calculi  is  to  be  found  in  the  secretion  of  a  bile  of  an  altered,  as 
compared  with  the  normal,  character ;  but  exact  investigations 
failed  to  substantiate  this  assumption.  It  is  more  probable,  as 
supposed  at  the  present  time,  that  biliary  calculi  are  formed 
within  the  normally  secreted  bile,  through  the  influence  of 
causes  which  emanate  from  the  intestinal  canal  and  which  call 
forth  a  precipitation  of  the  cholesterin,  of  the  biliary  pigments 
and  of  the  lime  salts  —  the  chief  component  bodies  of  biliary 
calculi.  According  to  some,  these  causes  (it  is  most  likely 
assumed,  that  it  is  the  microbes,  so  abundant  and  various  in 
the  intestinal  canal)  call  forth  a  catarrhal  condition  of  the  gall- 
ducts  and  of  the  gall-bladder,  which  impedes  the  passage  of  the 
bile  and  which,  through  its  products,  occasions  the  alterations 
in  this  fluid,  and  the  formation  within  it  of  the  above-named 
precipitates  ;  while  others  assert  that  these  causes  are  directly 
responsible  for  the  changes  produced  in  the  bile  and  its  pre- 
cipitates. All  these  assumptions  require  further  investigation 
and  verification. 

The  clinical  facts  coincide  in  so  far  with  these  suppositions, 
that  they  substantiate  the  frequency  of  the  co-existence  at 
one  and  the  same  time  of  gall-stones  and  of  a  catarrhal  con- 
dition of  the  biliary  passages  (it  must  in  this  connection  be 
kept  in  mind,  that  the  irritation  of  these  last  by  the  calculi  may 
also  lead  to  a  consequent  catarrh  of  the  same) :  constant  ten- 
derness, and  at  times  direct  sensitiveness  on  pressure  in  the 
region  of  the  gall-bladder,  and  frequent  jaundice  are  the  charac- 
teristic symptoms  of  biliary  calculi.  But  as  the  peculiarly 
characteristic  symptoms  of  this  disease  are  to  be  considered 
attacks  of  biliary  colic  accompanied  by  sharp,  at  times  excru- 
ciatmg   pain,  which    develops  rapidly,    and    which    disappears 


—  171  — 

after  a  certain  period  of  time  just  as  rapidly.  I  will  not 
stop  here  to  describe  an  attack  of  colic :  that  you  know  well 
from  your  study  of  special  pathology.  The  attacks  of  biliary 
colic  are  considered  as  due  to  neuralgia  of  the  hepatic  plexus, 
probably  in  conjunction  with  a  contemporaneous  tonic  spasm 
of  the  gall-bladder.  It  is  assumed  that  these  attacks  are 
caused  by  the  passage  of  the  calculi  through  the  narrow  por- 
tions of  the  biliary  tracts,  which  occasions,  as  a  consequence, 
an  irritation  of  these  last;  but  as  we  shall  see  later,  this  is 
hardly  always  the  case.  I  said  just  now,  that  as  the  most 
characteristic  symptoms  of  biliary  calculi  are  considered  the 
attacks  of  biliary  colic ;  but  it  would  be  very  erroneous  to 
thmk  that  their  absence  would  speak  against  the  presence 
of  biliary  calcuK.  On  the  contrary,  we  very  frequently  come 
across  cases  of  this  disease  which  do  not  present  attacks  of 
sharp  pain,  i.  e.  of  biliary  colic,  but  in  which  a  constantly 
present  pain  of  only  moderate  severity  in  the  region  of  the 
gall-bladder  is  observed,  of  which  the  patient  complams  himself, 
or  which  may  be  elicited  only  on  investigation  by  pressure. 
Sometimes,  in  these  cases,  in  their  further  course,  we  observe 
also  the  appearance  of  attacks  of  biliary  colic,  at  other  times 
we  do  not.  These  cases  yield  to  the  usual  treatment  of  bili- 
ary calculi,  as  do  cases  characterized  by  attacks  of  liver-colic. 
It  may  be  stated,  that  if  we  consider  the  attacks  of  biliary 
colic  as  the  most  characteristic  symptom  of  biliary  calculi,  then 
we  may  say  that  the  most  frequent,  and  the  most  constant 
symptom  of  this  disease,  is  a  constantly  present  pam  in  the 
region  of  the  gall-bladder,  aggravated  by  pressure. 

It  appears,  then,  that  our  patient  has  unmistakable  symptoms 
of  biliary  calculi  and  of  a  catarrh  of  the  biliary  ducts.  Even 
now  there  is  some  pain  in  the  region  of  the  gall-bladder,  ag- 
gravated on  pressure,  while  on  his  admission  it  was  much 
more  severe.  He  had  yesterday  quite  an  acute  attack  of 
biliary  colic,  and  slight  attacks,  as  seen  from  the  anamnesis, 
made  their  appearance  since  the  beginning  of  October.  While 
the  jaundice,  which  developed  in  connection  with  the  trifling 
and  rapidly  disappearing  gastro-intestinal  disturbance  (it  pre- 
sented on  the  patient's   admission    a    complete  failure   of   the 


—  172  — 

bile  to  enter  the  intestine),  proves  the  fact,  that,  up  to  the  time 
this  disturbance  made  its  appearance,  there  was  a  catarrhal 
condition  of  the  biliary  ducts,  severe  enough  to  become  exacer- 
bated from  a  trifling  cause. 

Some  consider  it  necessary  for  the  diagnosis  of  gall-stones  to 
search  for  passed  calculi  in  the  evacuations.  I  consider  such  a 
search  an  idle  task  for  practical  purposes.  In  the  great  ma- 
jority of  cases,  to  which  may  be  referred  the  present  one,  the 
diagnosis  is  easy,  and  does  not  present  any  difficulties.  In  the 
rare  cases  of  a  difficult  diagnosis,  the  detection  of  calculi  in 
the  excreta  is,  firstly,  of  such  casual  occurrence,  and  fails  so 
frequoiitiy,  that  it  can  not  be  relied  upon,  and,  secondly,  even 
when  successful,  it  is  of  but  small  assistance  in  the  matter. 
Let  us  touch  upon  these,  generally  quite  interesting,  cases  of 
difficult  diagnostication. 

It  is  at  times  necessary  to  decide  as  to  what  the  patient 
suffers  from  —  biliary  calculi  or  cancer  of  the  liver.  We 
usually  have  to  do  in  such  cases  with  very  emaciated  patients, 
who  present  a  slight  jaundice  and  who  have  severe  pains  in  the 
region  of  the  liver  (which  is  also  sensitive  on  pressure,  especially 
at  the  seat  of  the  gall-bladder),  but  without  any  pronounced 
objective  symptoms  of  cancer  of  that  organ.  A  search  is  made 
for  the  stones  in  the  evacuations,  and,  let  us  assume,  it  is 
successful  —  the  stones  are  found ;  but  will  this  fact  exclude 
a  contemporaneous  affection  by  a  cancer  (patients  who  suf- 
fer for  a  prolonged  period  with  gall-stones  become  quite 
frequently  victims  of  cancer  of  that  organ)  ?  And  to  settle 
the  fact  of  the  presence  or  absence  of  this  last  is  usually  the 
most  important  diagnostic  task  in  such  cases.  It  is  not  the 
detection  of  calculi  in  the  excreta,  but  the  careful  objective 
examination  and  attentive  analysis  of  the  patient's  past  and 
present  conditions,  of  the  course  of  the  disease, — ^at  times  it  is 
the  success  or  failure  of  the  treatment,  —  that  clear  up  the 
diagnosis  in  these  cases. 

We  further  meet  patients  with  symptoms  which  excite  a 
suspicion  of  both  gall-stones  and  of  disease  of  the  stomach, 
usually  of  an  ulcer  (less  frequently  of  cancer)  about  the  py- 
lorus :  such  patients  have  attacks  of  severe  pains,  with  vomit- 


—  173  — 

ing  (but  without  the  characteristic  icteric  phenomena  and 
without  blood  in  the  vomited  matter)  and  tenderness  on  pres- 
sure to  the  right  of  the  middle  abdominal  line,  between  the 
umbilicus  and  the  costal  edge,  at  a  seat  corresponding  at  times 
to  the  gall-bladder  and  at  other  times  to  the  gastric  pylorus. 
Here  also,  even  if  the  search  for  gall-stones  be  successful,  the 
question,  as  to  whether  there  is  not  also  with  the  biliary  calculi 
a  gastric  ulcer,  remains  unanswered;  here  also  the  diagnosis  is 
cleared  up  by  the  aid  of  the  same  procedure  as  in  the  foregomg 
case  (least  of  all,  however,  by  the  results  of  the  treatment,  that 
may  be  similar  in  both  diseases).  As  regards  the  objective  ex- 
amination in  such  cases,  I  will  say,  that  if  the  pain  is  felt 
distmctly  by  pressure  on  the  mentioned  region  in  the  direction 
upward,  toward  the  right  hypochondrium,  it  points  to  sensitive- 
ness of  the  gall-bladder,  but  if  the  pain  is  felt  in  the  direction 
downward  and  inward  (to  the  umbilicus),  then  it  is  sensitive- 
ness of  the  gastric  pylorus. 

Finally,  while  speaking  of  cases  in  which  the  diagnosis  of 
biliary  calculi  is  made  with  difficulty,  I  must  mention  the 
difference  between  them  and  the  attacks  of  neuralgia  of  the 
hepatic  plexus  caused  by  them  (i.  e.  of  attacks  of  biliary  colic) 
and  attacks  of  pure  neuralgia  of  the  plexus.  We  first  of  all 
ask  whether  there  is  such  a  thing  as  a  pure  neuralgia  of  this 
last?  Some  assume  that  there  is  :  thus  the  well-known 
clinician,  and  the  author  of  a  capital  work  on  diseases  of  the 
liver,  Frerichs,  described  a  case  of  biliary  colic,  for  which  re- 
peated treatment  at  Karlsbad  failed,  while  a  strengthening  and 
anti-nervine  treatment  was  successful,  and  he  considers  this 
case  as  one  of  pure  neuralgia  of  the  hepatic  plexus  (hepa- 
talgia).  But  Frerichs'  case  is,  in  my  opinion,  not  convincing, 
chiefly  because  the  anti-nervine  treatment  in  the  case  was 
preceded  by  the  repeated  treatment  at  Karlsbad :  it  is  probable 
that  this  last  removed  the  biliary  calculi,  while  the  attacks 
remained,  having  become  an  independent  hepatalgia,  which 
in  its  turn  yielded  later  on  to  the  anti-nervine  treatment.  An 
example  of  this  we  see  in  the  neuralgia  of  the  facial  nerve, 
caused  by  aching  teeth,  which  persists  (though  not  always, 
but  at  times  for  a  long  period)   after  these  are  cured  or  ex- 


—     174:     — 

tractecL  I  have  not  met  with  cases  which  could  be  considered 
as  presenting  a  genuine  and  withal  primary,  idiopathic  hepa- 
talgia,  but  I  have  frequently  seen  such  in  which  the  period 
of  undoubted  symptoms  of  gall-stones,  during  which  the  usual 
treatment  was  available  (calomel  and  mineral  waters),  was 
followed  by  one  in  which  the  attacks  of  biliar}^  colic  continued, 
although  somewhat  weaker,  and  only  yielded  to  treatment 
directed  towards  strengthening  the  condition  of  the  nervous 
system  (and  local  treatment  to  the  region  of  the  gall-bladder 
with  static  and  galvanic  electricity).  It  is  likely  that  the  cal- 
culi in  these  cases  have  already  disappeared  and  there  remained 
only  an  independently  established  biliary  colic  in  the  form,  con- 
sequently, of  a  hepatalgia  not  of  a  primary,  but  of  a  secondary 
origm,  consequent  upon  the  formerly  present  calculi.  The 
diagnostic  difficulties  for  me  consisted  not  in  my  inability  to 
make  up  a  decision,  as  to  whether  the  biliary  colic  in  the 
given  case  presented  symptoms  of  gall-stones,  or  whether  it 
was  a  primary  genuine  hepatalgia,  but  in  deciding  as  to  the 
period  of  the  disease,  whether  there  are  as  yet  present  biliary 
calculi  to  be  treated  accordingly,  or  whether  the  attacks  of 
biliary  colic  presented  an  established  neuralgia,  which  was  to  be 
treated  as  such.  It  is  not  always  easy  to  decide  on  this  point, 
and  a  conclusion  can  be  reached  through  a  careful  analysis 
of  the  condition  of  the  patient,  the  course  of  the  disease  and  the 
results  of  the  preceding  treatment ;  but  at  times  only  fresh 
therapeutic  attempts  decide  the  matter. 

The  present  case,  as  I  said  already,  does  not  belong  to  those 
in  which  a  diagnosis  is  difficult.  In  view  of  the  so  distinctly 
prominent  data  in  the  sphere  of  biliar}^  tracts  and  the  slight 
nervous  symptoms  in  our  patient,  pure  hepatalgia  is  positively 
to  be  excluded,  as  well  as  ulcer  of  the  stomach,  m  view  of  the 
condition  of  the  digestion,  and  finally  also,  cancer  of  any  organ, 
in  view  of  the  patient's  youth  and  physical  strength  as  well 
as  on  account  of  the  rapid  improvement  in  his  condition. 

Again,  there  are  cases  in  which  the  diagnosis,  properl}^  speak- 
ing, is  easy,  but  the  physician  —  certainly  if  negligent  —  may 
commit  an  error.  The  fact  is,  that  patients  suffering  from 
biliary  calculi,  who  do  not  have  any  attacks  of  biliary  colic,  but 


—  175  — 

only  a  constant  pain  in  the  region  of  the  gall-bladder,  complain 
frequently  of  pain  in  "the  pit  of  the  stomach,"  without  dis- 
tinctly designatmg  the  seat  of  pain,  which  is  so  easily  done 
in  view  of  the  vicmity  of  the  gall-bladder  to  the  "  pit  of  the 
stomach." 

The  physician,  yielding  to  the  first  impression,  mvestigates, 
makes  pressure  only  ia  the  region  of  the  stomach,  asks  the 
patient  about  it,  receives  in  reply  that  the  pain  is  aggravated, 
and  concludes  that  the  patient  has  a  gastric  catarrh ;  whereas  a 
careful  mvestigation,  i.  e.  such  as  would  also  include  the  neigh- 
boring organs,  would  show  in  such  cases  the  seat  of  the  max- 
imum sensitiveness  in  the  region  of  the  gall-bladder.  There 
may  certainly  be  present  at  one  and  the  same  time  both 
biliary  calculi  and  a  gastric  catarrh,  but  hi  such  a  case  we 
must  find  a  complete  summary  of  the  symptoms  of  both 
diseases. 

In  speaking  of  the  diagnosis,  we  must  say  a  few  words  con- 
cerning yesterday's  attack  of  biliary  colic.  The  patient  felt 
very  much  relieved  by  the  action  of  calomel :  the  sensitiveness 
on  pressure  in  the  region  of  the  gall-bladder  has  considerably 
diminished  since  then  and  remains  so  at  the  present  time. 
But  he  had  another  attack  of  colic  yesterday.  What  could 
have  caused  this  ?  The  usual  causes,  which  call  out  such 
attacks,  —  as  traumata  (as  we  saw  in  our  patient  when  it 
resulted  from  riding  in  a  jolting  wagon  over  the  pavement), 
mental  disturbances,  dietetic  errors,  and  colds  —  were  all  absent 
in  the  clinic.  We  can  only  say  this  much,  that  such  attacks 
are  frequently  observed  at  the  beginning  of  the  treatment  of 
biliary  calculi  with  Karlsbad  (or  generally  with  any  alkaline) 
water,  which  fact,  however,  prevents  in  no  way  its  further 
curative  action.*  The  above-mentioned  attack  was  accom- 
panied by  a  slight  febrile  condition  —  a  not  infrequent  phe- 
nomenon :  in  my  article  on  calomel  I  have  described  a  case  of 

*  A  similar  plienomenon  is  observed  in  the  treatment  of  renal  gravel 
by  mineral  waters,  namely,  the  attacks  of  renal  colic  appear  or  become 
aggravated  at  the  beginning  of  the  treatment;  so  that  in  either  case,  that 
is,  in  the  treatment  of  either  biliary  calculi  or  of  renal  gravel  by  min- 
eral waters,  it  is  advantageous  to  warn  the  patient  of  the  possibility  of 
such  an  initial  aggravation  of  the  attacks. 


—   176  — 

gall-stones,  in  which  the  attacks  of  biliary  colic  were  almost 
always  accompanied  by  a  febrile  condition. 

Prognosis  is  favorable :  the  disease  is  curable ;  but  the 
stability  of  recovery  and  the  absence  of  recurring  attacks 
depend  on  the  patient's  will  and  ability  to  fulfil  all  the  re- 
quirements of  hygiene  and  therapy. 

Treatment.  —  The  patient  was  at  first  given  calomel,  which  pro- 
duced such  a  considerable  and  usual  improvement  in  these 
cases.*  We  then  prescribed  the  warm  alkaline  and  slightly  lax- 
ative mineral  water  (Karlsbad  Miihlbrunnen).  Why  did  we 
prescribe  it?  Surely  not  because  we  were  guided  by  theoretical 
considerations,  which  change  m  accord  with  the  changes  in 
the  views  concerning  the  formation  of  gall-stones :  thus,  when 
the  cause  of  these  last  was  supposed  to  be  found  in  the  altera- 
tions of  the  secreted  bile,  then  the  eifect  of  alkaline  mineral 
waters  was  attributed  to  the  influence  on  the  secretion  of  bile, 
to  the  fact,  that  by  the  aid  of  the  alkaline,  the  secretion 
of  the  bile  becomes  more  abundant  and  more  fluid  (this  was 
evidently  also  substantiated  by  experimental  mvestigation),  and 
it  was  consequently  thought  that  it  would  thus  tend  to  dissolve 
and  remove  the  stones ;  at  the  present  time,  when  the  chief 
cause  of  the  formation  of  biliary  calculi  is  considered  to  be  due 
to  alterations  m  the  already  secreted  but  sluggishly  (stagna- 
tory)  passing  bile  on  account  of  the  catarrhal  condition  of  the 
biliary  tracts,  the  beneficent  influence  of  the  mineral  alkaline 
waters  on  the  gall-stones  is  chiefly  ascribed  to  their  action  on 
this  catarrhal  condition.  There  is  perhaps  to  an  extent  some 
truth  in  either  of  the  views,  but  the  chief  guide  for  the  employ- 
ment of  mineral  alkaline  waters  in  gall-stones  are  not  all  these  as- 
sumptions, but  the  facts  that  practice  has  proved  the  utility  of 
the  employment  of  these  waters  for  this  disease  and  has  taught 
the  method  of  employing  them. 

Why  did  we  prescribe  Karlsbad  water,  and  no  other  alka- 
line water,  as  Ems,  Marienbad,  Vichy  and  Yessentucki?  I  had 
occasion  to  go  into  particular  explanations  regarding  the  selec- 

*  The  indications  for  calomel  for  biliary  stones  liave  been  fully  discussed 
by  me  in  my  article  on  calomel,  and  to  avoid  repetitions,  I  must  refer  the 
reader  to  it. 


—  177  — 

tion  of  mineral  waters  ;  I  would  therefore,  for  the  sake  of  a  short 
explanation  of  the  present  case,  say  but  a  few  words.  If  the 
patient  were  subject  to  diarrhoea,  we  would  give  him  Ems ;  but 
as  he  is  slightly  costive,  he  was  given  Karlsbad.  As  a  strongl}^ 
laxative  water  Marienbad  is  not  indicated  in  this  case,  and  being 
a  cold  water  and  rich  in  carbonic  acid,  it  would  tend  to  aggra- 
vate the  pains,  and  is  consequently  contra-indicated.  If  the  he- 
patic colic  and  the  gall-stones  would  play  but  a  subordmate  part 
m  our  case,  and  the  principal  trouble  would  consist  in  renal 
colic  and  renal  uric-acid-gravel,  while  the  patient  himself  would 
present  unmistakable  symptoms  of  gout  (arthritis  urica),  then 
we  would  prescribe  Vichy,  Yessentucki  (warmed),  etc. 

The  patient  declares,  that  as  he  apprehends  the  loss  of  his 
occupation,  he  would  like  to  leave  the  clmic  as  soon  as  possible  ; 
we  will  therefore  prescribe  for  him  a  somewhat  larger  dose  of 
Karlsbad  than  what  is  usually  admmistered  during  the  cold  sea- 
son of  the  year  with  constant  coniinement  within  the  house : 
thus,  the  day  before  yesterday  our  patient  drank  one  half-glass- 
ful of  the  above-named  water,  yesterday  he  had  two  half-glass- 
fuls ;  we  will  prescribe  to-day  three,  and  from  to-morrow  he  will 
take  four  half-glassfuls,  two  doses  one  hour  before  the  early 
(mid-day)  dinner,  in  the  interval  of  one-quarter  of  an  hour  one 
from  the  other,  and  the  other  two  one  hour  before  supper  (7 
P.M.)  in  the  same  order.  The  gradual  increase  in  the  quantity  of 
the  mineral  water,  beginning  with  one  half-glassful  per  day,  is  in- 
dicated in  the  present  case  by  the  fact,  that  first  the  patient  had 
recently  a  diarrhoea,  and  secondly,  he  had  only  lately  loose  stool 
from  calomel :  four  half-glassfuls  of  Mlililbrunnen  from  the  very 
first  day  would  have  caused  a  diarrhcjea,  which  is  far  from  being- 
desirable. 

Besides  the  Miihlbrunnen  we  shall  order  for  the  our  patient 
a  warm  bath,  which  we  are  likely  to  repeat,  as  a  very  beneficial 
agency  in  pains  caused  by  biliary  calculi  and  by  catarrhal 
jaundice.  In  case  the  patient  has  another  attack  of  biliary  col- 
ic, he  will  get  one  or  two  doses  of  one-fourth  of  a  graui  of 
codeine,  which,  to  judge  by  yesterday's  attack,  is  sufiicient  to 
subdue  the  pain  (in  very  acute  attacks  a  resort  to  morphine  be- 
comes necessary).     The  patient,  as  I  said  before,  is  somewhat 


—  178  — 

nervous  and  subject  to  sleeplessness  :  he  will  be  given  at  times  a 
few  drops  of  the  sether-valeriana  preparation  (the  more  so,  as  the 
pulse  becomes  weak  at  times),  and  at  bedtime,  to  overcome  the 
sleeplessness,  daily  doses  of  fifteen  grains  of  potassium  bromide. 


FROM  THE  LECTURE  OF  OCTOBER  27,  1889. 

Status.  —  There  were  no  attacks  of  biliary  colic,  the  temper- 
ature is  normal,  there  is  improvement  all  around.  The  former 
treatment  will  be  continued. 


FROM  THE  LECTURE  OF  NOVEMBER  15. 

Status.  —  The  patient,  as  you  hear,  declares  that  he  is  com- 
pletely cured.  As  a  matter  of  fact,  his  appetite  and  digestion 
are  normal  (stool  for  the  last  few  days  without  a  clyster),  the 
jaundice  disappeared,  attacks  of  biliary  colic  are  absent,  there 
is  neither  pain,  nor  tenderness  on  pressure  in  the  region  of  the 
gall-bladder,  the  sleep  is  sound  (he  was  given  the  bromide  only 
during  one  week),  and  the  mental  condition  is  hale  (we  found 
it  necessary  to  give  him  only  two  warm  baths,  while  for  the  few 
last  days  he  was  given  cool  spongings  20° JR..  (about  11° F.'), 
with  a  mixture  of  water  and  brandy,  which  exerted  a  beneficial 
influence  on  his  nervous  system).  Until  to-day,  patient  drank  of 
Miihlbrunnen  four  half-glasses  daily ;  to-day  we  will  give  him 
only  two  haK-glassfuls,  because  his  affairs  require  that  he  leave 
the  clinic  to-morrow. 

The  patient  was  made  to  understand  that  onl}^  the  visible  symp- 
toms of  his  disease  had  disappeared,  that  time  would  show  how 
lasting  his  recovery  would  be,  and  that  to  avoid  the  return  of  the 
morbid  attacks,  he  must  beware  of  irregularities  in  his  mode  of 
living,  which  we  discovered  by  our  investigation  (his  sojourn  in 
our  clinic  has  served  as  a  good  hygienic  schooling  for  our  pa- 
tient). We  told  him  that  it  may  very  likely  become  necessary 
to  resort  to  repeated  treatment  by  Miihlbrunnen,  and  that  this 
treatment  must  be  postponed  till  the  warm  season  of  the  year, 
(i.  e.  so  as  to  avoid  at  least  until  then  a  return  of  the  morbid 


—  179  — 

attacks),  when  he  would  be  able  to  undergo  treatment  by  mui- 
eral  waters,  without  being  compelled,  at  least  altogether,  to 
give  up  his  occupation. 

I  do  not  advise  our  patient  to  drink  any  Miihlbrunnen  at  home, 
first,  because  at  the  present  season  of  the  year,  with  his  occupa- 
tion out-of-doors,  it  would  subject  him  to  a  risk ;  and  secondly, 
because  the  drmking  for  twenty-four  days  of  the  Miihlbrunnen, 
which  he  finishes  to-day,  may  perhaps  suffice ;  already  for  the 
last  ten  days  there  is  no  jaundice,  nor  any  pain  in  the  region  of 
the  gall-bladder,  while  no  attack  of  biliary  colic  took  place  since 
the  one  of  which  we  spoke  October  25th.  In  other  cases  it  is 
frequently  necessary  to  prolong  the  course  of  treatment  with 
mineral  waters  for  six  weeks.  Further  than  that  I  usually  do 
not  continue  the  treatment  with  mineral  waters,  but  make  an 
interruption,  and  if  necessary,  repeat  it ;  I  do  this  because,  fii'st, 
a  more  prolonged,  uninterrupted  employment  of  mineral  waters 
may  exert  a  deleterious  influence  on  nutrition  and  digestion, 
and  secondl}^,  to  enable  me  to  clearly  define  the  results  obtamed 
by  the  treatment.  If,  during  this  necessary  interruption  the 
patient  be  sulf  ering  with  pains  in  the  region  of  the  gall-bladder, 
I  then  prescribe  ether,  —  ten,  fifteen  or  twenty  drops  three  times  a 
day  (exercise  special  care,  so  as  to  administer  the  smallest 
dose  to  men  already  advanced  in  age,  who  may  have  a  hyper- 
trophy of  the  heart,  or  in  whom  it  is  generally  easily  excitable), 
or,  for  men  with  good  digestion,  ether  (§j)  and  oleum  tereben- 
thinse  rectificatum  (3j)  in  the  above-named  dose.  These  reme- 
dies (the  remedy  of  Durande  consists,  properly  speaking,  of  one 
part  of  oleum  tereb.  and  four  parts  of  ether)  are  sometimes  un- 
doubtedly effective. 

But  ordinarily  I  contmue  the  treatment  of  gall-stones  until 
all  their  symptoms  have  disappeared  (and  even  somewhat  be- 
yond that  time) ;  chiefly  not  the  attacks  of  biliary  colic  (which 
appear  so  vaguely,  that  they  can  hardly  serve  as  a  guide),  but 
the  constant  pains  and  sensitiveness  on  pressure  at  the  seat  of 
the  gall-bladder.  It  is  always  a  most  reliable  way  to  be  guided 
by  these  last  symptoms ;  the  attacks  of  biliary  colic,  however, 
cease  usually  before  the  disappearance  of  the  above-named  con- 
stant pains  and  of  the  sensitiveness  on  pressure. 


—  180  — 

While  discontinuing  the  treatment,  as  per  above-named  indi- 
cations, I  am  far  from  assummg  that  the  gall-stones  have  been 
"cured,"  removed,  or  are  absent:  we  frequently  observe  cases, 
where  the  above  enumerated  symptoms  have  disappeared,  and 
the  patient  feels  absolutely  no  pain  in  the  region  of  the  gall- 
bladder, no  attacks  of  biliary  colic  have  taken  place  for  a  very 
long  time,  and  the  patient  leads  a  faultless  hygienic  life,  when 
all  at  once,  through  an  accidental  cause  (most  frequently  follow- 
ing strong  mental  excitement)  an  acute  attack  of  biliary  colic 
breaks  out  unexpectedly,  showing  the  presence  as  yet  of  one  or 
many  stones  in  the  bladder.  It  is  true  such  cases  are  very  rare ; 
ordinarily  the  return  of  the  attacks  of  biliary  colic  is  preceded 
by  a  return  of  a  constant,  although  slight,  pain  and  sensitiveness 
on  pressure  in  the  region  of  the  gall-bladder,  that  reminds  us  of 
the  necessity  for  a  repetition  of  the  treatment  and  usually  of  the 
necessity  for  a  stricter  observance  of  hygienic  rules.  But,  I  re- 
peat again,  the  treatment  must  be  conducted  only  till  the  disap- 
pearance (and  somewhat  longer)  of  the  above-named  symptoms. 
To  continue  treatment  until  "  the  stones  have  completely  disap- 
peared," is  unreasonable  (not  to  speak  of  the  possible  danger  from 
a  too  prolonged  treatment),  because,  what  can  guide  us  in  pro- 
longing the  treatment,  and  for  how  long  a  period  can  we  do  it? 
Then  there  is  no  necessity  for  it :  experience  shows,  that  with 
the  observance  of  hygiene,  with  regularity  in  all  the  functional 
activities  of  the  organism,  calculi  may  remain  in  the  bladder 
without  giving  rise  to  any  morbid  phenomena ;  but  if  the 
hygienic  rules  be  neglected  and  there  be  superadded  gastro-intes- 
tinal,  nervous  and  other  disturbances,  then  even  the  complete 
removal  of  the  stones  (if  such  be  successfully  accomplished)  will 
be  of  no  avail,  as  others  will  be  formed  again.  I  alluded  once 
already  to  the  fact,  that  on  the  return  of  the  symptoms  at  the 
seat  of  the  gall-bladder  it  is  necessary,  in  order  to  anticipate  an 
attack  of  biliary  colic,  to  repeat  the  treatment  with  mineral 
water. 

Sodium  salycilate  and  olive  oil,  recommended  recently  for  the 
treatment  of  biliary  calculi,  do  not,  in  my  opinion,  deserve  any 
consideration. 

The    present  case  does  not  present  sufficient  cause  for  the 


—  181  — 

discussion  of  the  operative  treatment  of  biliary  calculi,  which  is 
at  times  (to  be  sure,  in  conjunction  with  correct  therapy  and 
regimen,  in  very  rare  cases)  the  sole  means  for  the  relief  of  the 
unbearable  sufferings  or  even  the  means  of  saving  the  patient's 
life. 


SEVENTH    CASE, 


LECTURE  OF  MARCH  24,  1892. 

The  patient,  a  private  of  the  reserve  army,  complains  of  jaun- 
dice, enlargement  of  the  abdomen,  oedema  of  the  legs,  a  febrile 
condition  and  general  weakness. 

Mode  of  living  and  anamnesis.  —  Patient  lives  in  a  healthy,  non- 
malarial  locality  (a  village)  of  the  Vladimir  Government. 
The  residence  is  an  ordmary  peasant's  house,  the  stable  serves  as 
a  water-closet.  Used  to  bathe  durmg  summer  until  the  appear- 
ance of  his  sickness.  Takes  a  hot  bath  every  week.  Smokes 
some  and  is  a  moderate  tea-drmker,  but  drinks  daily  a  goodly 
quantity  of  whiskey  and  at  times  considerable  of  it.  His  board 
is  good.  He  is  single.  Denies  syphilitic  infection,  and  investi- 
gation substantiates  this  denial.  In  view  of  his  sickness  he 
has  had  no  occupation  lately,  but  served  in  the  army  formerly. 

Patient  comes  from  a  healthy  family.  He  began  drinking 
whiskey  when  eighteen  years  old  and  suffered  since  then  with 
burning  and  belching  after  meals.  Entered  the  military  service 
in  his  twenty-first  year  (served  as  an  artillery  man  in  Warsaw), 
when  he  was  compelled  to  abstain  from  drmking,  and  noticed 
that  both  the  burning  and  the  belching  disappeared ;  but  in  June 
1891,  he  seems  to  have  passed  through  an  attack  of  typhus 
(during  six  weeks  he  had  suffered  from  high  fever,  debility  and 
unconsciousness),  after  which,  at  the  end  of  July,  he  was  given 
a  leave  of  absence  "  to  recover  his  health."  He  began  drinking 
while  at  home,  when  there  soon  reappeared  belching,  burning 
and  pams  in  the  stomach,  especially  after  a  cold  drink  and 
rough  food.  By  the  end  of  September  there  appeared  the  jaun- 
dice, and  at  the  same  time  the  gastric  symptoms  became  aggra- 
vated, especially  the  pains,  which  were  this  time  accompanied 
by  vomiting.     The  patient  left  off'  drinkuig,  became  more  care- 


—  183  — 

ful  witli  his  food,  and  took  some  Karlsbad  salts  and  some  pow- 
ders (apparently  containing  rhubarb)  ;  by  the  middle  of  Novem- 
ber the  pains  and  dyspeptic  phenomena  were  relieved  and  the 
jaundice,  as  he  claims,  disappeared.  Patient  again  took  to 
drinking,  and  again  there  appeared  jaundice,  pains  and  vomiting 
(now  of  daily  occurrence),  and  also  a  slight  febrile  condition, 
enlargement  of  the  abdomen,  cedema  of  the  legs  and  general 
weakness.  Patient  entered  our  clinic  the  first  time  December 
6th,  with  the  following  most  important  data  (besides  those 
above  enumerated) :  the  liver  is  very  much  enlarged,  firm, 
smooth  (edge  sharp),  not  tender  to  pressure,  nor  is  the  region 
of  the  gall-bladder  sensitive ;  the  faeces  are  but  slightly  colored 
by  bile,  the  urine  is  very  much  jaundiced,  contains  neither  albu- 
men nor  sugar ;  the  spleen  is  slightly  enlarged,  there  is  moder- 
ate ascites ;  the  heart  is  somewhat  raised  by  the  high  position 
of  the  diaphragm,  its  tones  are  clear,  the  pulse  is  weak ;  the  or- 
gans of  respiration  and  the  nervous  system  are  m  a  normal  con- 
dition. The  patient  was  prescribed  a  diet,  Ems,  the  bitters 
(extr.  condurango  fl.  and  tra.  nux  vom.)  and  stimulating  drops 
(tra.  valer.  aether,  and  liqu.  anod.  Hoff.  aa) ;  the  vomiting 
ceased,  and  the  dyspeptic  phenomena  were  relieved. 

December  11th  he  was  given  ten  powders  of  calomel  aa 
gr.  j,  after  which  he  had  abundant  loose  characteristic  calomel 
stools,  followed  by  almost  normally  colored  evacuations,  while 
the  urine  became  more  limpid  and  the  febrile  condition  passed 
away.  After  the  calomel  we  continued  the  former  treatment 
(Ems,  bitters  and  stimulants),  but  December  20th,  the  pa- 
tient, before  the  termination  of  the  laid-out  plan  of  treatment, 
left  our  clinic,  considerably  improved  however :  the  jaundice 
and  the  dyspeptic  phenomena  have  almost  completely  passed 
away,  as  well  as  the  oedema  of  the  legs,  the  ascites  diminished, 
and  his  strength  began  to  return.  After  leaving  the  clinic 
the  patient  again  took  to  drinking  and  began  eating  indiscrimi- 
nately, but  this  notwithstanding  he  felt  comfortably  well  until 
the  middle  of  February.  Since  then  his  condition  grew  rapidly 
worse  :  there  appeared  considerable  jaundice,  almost  daily  vom- 
iting and  diarrhoea  (three  to  four  very  fluid,  painless  stools  per 
day),  the  abdomen  enlarged  rapidly,  the  legs  became  oedematous, 


—  184  — 

there  appeared  a  febrile  condition  with  daily  chills,  weakness 
and  later  on  haemorrhage  from  the  nose  and  gums,  and  hemera- 
lopia.     He  was  again  admitted  to  our  clmic  March  loth. 

Since  admission  patient  has  been  taking  all  the  time  remedies 
to  strengthen  the  heart's  action  (wine,  tra.  valer.  aether.  +  liqu. 
Anodyn.  Hoffm.,  twenty-five  drops  four  times  a  day,  and  fre- 
quently caffeinum  natro-salycil.,  five  grains  three  times  a  day), 
and  December  17th  he  was  given  five  one-gram  powders  of 
calomel  with  good  effect.  The  febrile  condition,  which  reached 
in  the  evenings  40.2°  (104.5  ^.),  diminished  after  the  admin- 
istration of  the  calomel  and  later  disappeared  altogether,  so  that 
it  was  entirely  absent  these  last  three  days ;  but  to-day  he  had 
again  a  slight  chill.  The  urine  became  more  limpid  after  the 
calomel,  while  the  evacuations  are  tolerably  colored  and  became 
less  frequent  and  more  solid  (twice  a  day).  The  dyspeptic 
phenomena  passed  away.  The  pulse  and  general  condition  of 
the  patient  became  better,  but  the  ascites  is  on  the  increase. 

Status.  —  A  slight  appetite  appeared.  With  the  disappearance 
of  the  fever  the  thirst  diminished  and  the  dryness  of  the  tongue 
passed  away.  The  gums  are  spongy  and  bleed.  The  pain  in 
the  stomach,  the  vomiting  and  the  other  dyspeptic  phenomena 
passed  away.  The  stools  are  as  above.  The  urine  is  less 
jaundiced,  than  it  was  on  the  patient's  admission,  contains 
neither  albumen  nor  sug-ar,  its  quantity  amounts  to  1,500  c.  c. 
There  are  no  pains  in  the  abdomen,  the  ascites  is  very  consider- 
able, the  superficial  abdominal  veins  appear  very  much  dis- 
tended. The  ascites  does  not  permit  of  palpating  the  liver  and 
the  spleen  at  present,  but  on  his  admission  investigation 
showed,  that  the  liver  was  very  much  enlarged  (its  free  edge  is 
some  four  fiugers'  width  below  the  normal),  but  otherwise  m 
the  same  condition  as  it  was  during  the  patient's  first  sojourn  in 
the  hospital ;  it  is  also  perfectly  msensitive  to  pressure  (and  so 
is  the  region  of  the  gall-bladder),  although  the  spleen  emerges 
one  and  one-half  to  two  fingers'  width  from  under  the  edges  of 
the  ribs  (patient  never  had  malaria),  it  is  firm  and  also  insen- 
sitive. The  heart  is  raised  by  the  high  position  of  the  dia- 
phragm, but  it  is  not  enlarged ;  at  both  the  apex  and  the  base 
there  is  a  perceptible  systolic  murmur  of  equal  intensity. 


—  185  — 

Pulse  112,  regular,  stronger  than  it  was  on  his  admission,  but 
still  somewhat  weak.  There  is  no  pam  in  the  chest :  d.js23n(t!a 
on  moving  about  (when  at  rest,  respiration  30  per  minute), 
a  slight  cough  with  a  trifling  amount  of  mucous  expectoration; 
auscultation  elicits  some  dry  rales  here  aiid  there ;  the  voice  is 
very  hoarse  (laryngoscopic  examination  shows  a  catarrhal  con- 
dition of  the  vocal  cords).  Patient  is  very  thin  and  weak. 
We  alluded  above  to  the  febrile  condition ;  with  its  disappear- 
ance the  sleep  became  better,  while  the  formerly  occurrmg  (in 
the  evening  during  the  increase  of  the  fever)  headaches  have 
almost  completely  disappeared.  Movement  gives  rise  to  dizzi- 
ness. The  consciousness  is  clear,  but  the  memory  has  weakened 
somewhat  durmg  the  last  half-year.  The  mental  condition  is 
oppressed.  There  is  hemeralopia.  Hearing  is  normal.  No 
pains  in  the  back,  arms  and  legs.  The  legs  up  to  the  knees 
are  considerably  (jedematous.  Severe  jaundice:  the  sclerotics 
and  the  visible  mucous  membranes  are  colored  yellow,  the  skin 
brown-yellow. 

'  Diagnosis.  —  The  dyspeptic  phenomena  as  well  as  the  pains  in 
the  stomach,  which  appeared  with  such  regularity  while  the 
patient  was  drinking  and  committing  dietetic  errors,  and  which 
passed  away  as  soon  as  the  patient  gave  up  drinking  and  exercised 
due  care  in  his  food  and  which  so  rapidly  yielded  to  the  treatment 
by  Ems  water  and  bitters  durmg  the  first  sojourn  of  the  patient  m 
the  clinic,  point  undoubtedly  to  a  catarrh  of  the  stomach.  Caused 
at  the  beginnmg  by  excesses  in  drinking  whiskey  and  by  dietetic 
errors,  this  sickness  is  now  perpetuated  by  the  so  markedly  appa- 
rent impediment  in  the  circulation  of  the  vena  portse  due  to  the 
disease  of  the  liver.  The  diarrhcjea,  too,  is  chiefly  to  be  ascribed 
to  this  impediment  m  the  circulation :  the  trifling  admixture  of 
mucus  in  the  evacuation  points  only  to  an  msignificant  intesti- 
nal catarrh,  while  the  evacuations,  although  mfrequent,  are  abun- 
dant, watery  and  entirely  miaccompanied  by  pains  (m  a  catarrh, 
on  the  contrary,  they  would  rather  be  frequent,  not  so  abundant, 
rather  more  of  a  mucous  than  of  a  liquid  nature,  and  to  a  great- 
er or  lesser  extent  accompanied  by  pains).  The  urinary  organs, 
outside  of  the  presence  of  biliary  elements  in  the  urine  are 
healthy.     Except  for  the  pains  in  the  stomach,  which  were  ac- 


—  186  — 

companied  by  vomiting  and  which  disappeared  now,  the  abdo- 
men is  entirely  painless  and  has  always  been  so ;  in  view  of  this 
we  must  consider  the  great  ascites  in  our  patient  as  a  result  of 
the  impeded  circulation  of  the  vena  portse,  which  fact  is  also 
substantiated  by  the  considerable  distention  of  the  subcutaneous 
abdominal  veins,  by  the  above-named  diarrhoea  and  by  the  en- 
largement and  thickening  of  the  spleen. 

This  last  condition  cannot  be  referred  to  anything  else :  the 
patient  never  suffered  with  malaria,  while  there  is  no  sufficient 
reason  to  ascribe  this  enlargement  to  the  results  of  an  (assumed) 
former  typhus ;  such  an  enlargement  and  thickening  of  the 
spleen  is  rather  unusual  after  typhus.  The  sharply  pronounced 
symptoms  speak  clearly  for  an  affection  of  the  liver  and  of  the 
biliary  passages,  but  this  we  shall  discuss  at  the  end,  after  we 
will  have  analyzed  the  condition  of  the  other  parts  of  the  organ- 
ism. The  catarrhal  condition  of  the  pharynx,  larynx  and  the 
slight  bronchial  catarrh,  so  usually  seen  in  drinkers,  requires  no 
special  explanations.  The  cause  of  the  displacement  of  the 
heart  upward  is  clear.  The  weakness  of  the  pulse  and  the  sys- 
tolic murmur  may  depend  partly  on  the  displacement  of  the 
heart,  partly  on  trophic  changes  in  the  cardiac  muscle  (which  it 
would  be  so  natural  to  find  in  a  patient,  who  passed  but  recent- 
ly through  a  severe  febrile  affection,  and  who,  this  is  most  im- 
portant, has  so  ruined  his  health  in  general,  and  particularly  his 
nutrition,  by  drinking)  and  partly  on  account  of  some  distur- 
bance of  the  mnervation  of  the  heart  caused  by  chol?emia,  the 
presence  in  the  blood  of  biliary  elements,  because  the  patient 
presents  already  unmistakable  signs  of  the  presence  of  cholsemic 
phenomena  —  bleeding  of  the  gums  and  hemeralopia. 

There  is  not  the  slightest  foundation  for  considermg  the  sys- 
tolic murmur  as  a  symjDtom  of  affection  of  a  cardiac  orifice  or  of 
a  corresponding  valve,  first  because  the  most  important  proof  of 
the  existence  of  such  an  affection^ a  resultmg  enlargement 
of  the  heart  —  is  absent,  and  secondly  because  m  December, 
during  the  patient's  first  sojourn  in  the  clinic,  the  tones  of  the 
heart  were  clear,  there  were  no  murmurs,  although  the  principal 
morbid  phenomena  in  our  patient  (the  abdominal)  were  already 
at   that   time  in  evidence,   though  to  a  slighter  degree.     The 


—  187  — 

frequency  of  the  pulse  is  due  to  the  same  causes,  and  also  un- 
doubtedly to  the  febrile  condition.  The  oedema  of  the  legs  is 
kept  up  by  the  weakness  of  the  pulse,  but  it  certainly  depends 
principally  on  the  pressure  of  the  fluid  (which  accumulated  m 
the  peritoneal  cavity  and  distended  the  abdomen),  exerted  on 
the  inferior  vena  cava  and  the  great  veins  of  the  abdominal  cavi- 
ty terminating  in  it.  We  can  find  no  other  causes  for  the  feb- 
rile condition  outside  of  disease  of  the  liver  and  of  the  biliary 
passages.  After  all  that  was  said,  we  hardly  need  to  stop  here 
for  the  explanation  of  the  nervous  symptoms. 

What  disease  of  the  liver  does  our  patient  have?  I  must 
first  of  all  observe,  that  cases  of  hepatic  diseases,  in  which  the 
diagnosis  is  directly  apparent  by  the  collection  of  the  symptoms, 
are  less  frequently  seen,  than  such  which  for  their  diagnostica- 
tion  require  a  resort  to  differential  diagnosis ;  as  an  example  of 
the  first  class,  we  may  instance  a  case  in  which  a  large,  painless 
liver  with  undoubted  fluctuation  at  some  point  on  its  surface  in 
conjunction  with  a  complete  absence  of  any  other  morbid  data 
either  m  the  liver  itself,  or  in  the  rest  of  the  organism,  points  at 
once  to  an  echinococcus  cyst  of  this  organ,  or  when  an  enlarged, 
tuberous  and  extremely  sensitive  liver  in  a  cachectic  patient, 
who  is  apparently  free  from  syphilis,  speaks  for  cancer  or  gener- 
ally for  a  malignant  new  formation  in  this  organ.  Our  present 
case  belongs  to  the  second  class  of  cases,  and  we  will  therefore 
apply  to  it  the  above-named  method  of  differential  diagnosis. 
It  is  evident  that  the  sum  total  of  the  symptoms  in  our 
patient  can  not  be  ascribed  to  either  hypersemia  of  the  liver,  or 
to  fatty  degeneration  of  this  organ.  Amyloid  degeneration  of 
the  liver  is  to  be  excluded  by  the  considerable  ascites,  by  the 
phenomena  of  icterus  and  the  absence  of  albuminuria,  which 
could  be  expected  as  a  symptom  of  a  contemporaneous  amyloid 
affection  of  the  kidneys,  if  we  admit  such  an  advanced  amyloid 
degeneration  in  our  patient  as  would  be  necessary  to  assume 
in  order  to  explain  the  great  enlargement  of  the  liver  as  well  as 
of  the  spleen.  Syphilis  of  the  liver  could  give  rise  to  the  symp- 
toms observed  in  our  patient  (with  the  addition,  however,  of 
pains  in  the  hepatic  region,  which  usually  accompany  syj)hilis 
of  this  organ,  but  which  were  and  are  now  absent  in  the  present 


—  188  — 

case)  ;  but  this  is  not  onl}^  to  be  excluded  by  the  fact  that  the 
patient,  not  by  any  means  a  man  of  deceitful  nature,  denies 
syphilitic  infection,  but  chiefly  by  the  fact,  that  neither  the  an- 
amnesis nor  the  present  history  give  the  least  clue  as  to  its  pres- 
ence. Against  cancer  of  the  liver  speak  the  patient's  youth,  the 
absence  of  roughness,  and  complete  insensitiveness  of  this  organ, 
as  well  as  the  repeated  improvement  (and  even  disappearance) 
of  the  phenomena  of  icterus  and  the  parallel  cessation  of  the  feb- 
rile condition  after  the  employment  of  calomel,  which  could 
not  be  thought  of,  were  they  conditioned  by  cancer  of  the  liver, 
Echinococcus  cyst  could  not  give  rise  to  the  symptoms  ob- 
served in  our  patient,  not  to  mention  the  fact  of  the  absence  of 
any  symptoms  of  this  affection  (fluctuation).  Multilocular 
echinococcus,  which  emigrated  into  the  biliary  passages  and 
caused  the  chronic  jaundice,  differs  from  the  present  case  in 
this,  that  it  occasions  a  very  pronounced  alteration  in  the  shape 
of  the  liver  (the  right  lobe  is  particularly  enlarged),  that  it 
takes  a  more  chronic  course,  is  usually  unaccompanied  by  as- 
cites, and  especially  of  such  magnitude,  but  principally  by  the 
fact,  that  a  diminution,  the  more  so  the  disappearance,  of  the  icte- 
rous  symptoms  caused  by  it,  is  never  effected  by  the  employ- 
ment of  calomel.  There  remams,  therefore,  that  disease  of  the 
liver,  which,  in  view  of  the  etiology  of  the  given  case  —  abuse  of 
alcohol  in  conjunction  with  an  assumed  attack  of  typhus  — 
would  first  of  all  suggest  itself,  namely  cirrhosis  of  the  liver,  as 
a  result  of  an  interstitial  inflammation  of  the  organ  (hepatitis 
interstitialis). 

Our  knowledge  of  the  cirrhoses  of  the  liver  is  far  from  being- 
perfect.  The  pathologo-histological  data  concerning  these  af- 
fections are  interpreted  in  various  ways.  As  based  on  these, 
some  assume  the  following  cirrhoses  :  vevious,  in  which  the  inter- 
stitial inflammation  begins  from  the  branches  of  the  vena  portse  ; 
biliary,  in  which  it  progresses  from  the  small  biliary  passages, 
and  the  mixed,  when  the  disease  advances  contemporaneously 
from  both  the  venous  and  the  biliary  branches ;  others  again  as- 
sume that  there  is  only  one  kmd  of  cirrhosis,  that  the  interstitial 
inflammation  of  the  liver  involves  at  the  same  time  both  the 
branches  of  the  vena  portye  and  the  biliary  ducts  and  that  it 


—  189  — 

only  predominates  to  a  greater  extent  in  one  case  around  the 
first,  in  the  other  case  around  the  second,  but  that  eventually 
it  spreads  everywhere.  The  clinic  proves  the  following :  there 
are,  iirst,  cases  of  cirrhosis,  which  present  only  results  of  im- 
peded venous  circulation  in  the  liver  (as  ascites,  enlarged 
spleen,  diarrhoea,  intestinal  as  well  as  gastric  haemorrhages) 
without  an  arrest  in  the  flow  of  bile ;  second  —  cases,  in  which, 
on  the  contrary,  the  last  condition  is  observed,  without  any 
disturbance  of  the  circulation  of  the  portal  vein ;  and  third, 
- — such,  where  both  classes  of  symptoms  are  to  be  seen.  It 
appears  then,  that  the  clinical  data  are  in  greater  accord  with 
the  first  of  the  above-named  views,  which  was  first  promulgated 
by  the  French  investigators  Charcot,  Hanot  and  others ;  the 
second  one  is  defended  by  the  Germans. 

It  is  also  from  an  etiological  point  of  view  more  probable, 
that  m  some  cases  the  exciting  agencies  of  the  inflammation 
reach  the  liver  through  the  blood  vessels,  in  others  through 
the  biliary  ducts  (from  the  intestinal  canal)  and  in  others 
agam  contemporaneously  through  both  tracts.  The  fact,  that 
the  interstitial  inflammation,  originating  at  one  point,  for  in- 
stance at  the  biliary  ducts,  and  accompanied  at  the  beginning 
only  by  signs  of  an  arrested  flow  of  bile,  may  later  on  spread 
also  over  the  circumference  of  the  system  of  the  vena  portse 
and  give  rise  to  phenomena  of  disturbed  circulation  in  this 
last,  can  surely  not  serve  as  a  proof  that  the  process  com- 
menced everywhere  at  one  and  the  same  time.  I  will  also 
say  that  in  cases  of  cirrhosis  accompanied  by  disturbances  of 
the  portal  venous  circulation,  the  liver  is  sometimes  very  much 
diminished  in  size  (the  cirrhosis  first  described  by  Laennec, 
called  by  his  name),  at  other  times  it  is  greatly  enlarged. 
Some  think  that  such  an  enlargement  takes  place  only  at  the 
beginnmg,  and  that  later  on  it  is  followed  by  a  diminution 
m  size,  and  that  if  this  decrease  does  not  take  place,  it  is  to 
be  ascribed  to  the  fact  that  the  exhausted  patient  does  not 
last  long  enough  for  this  process  to  develop. 

As  a  matter  of  fact,  it  has  been  proved  by  various  investi- 
gations that  the  liver,  enlarged  at  the  beginning,  undergoes 
a  process  of  shrinkmg  later  on.     But  we  much  more  frequently 


—  190  — 

meet  cases,  in  which  the  liver  remains  enlarged  up  to  the 
patient's  death,  although  the  patient  may  live  long  enough, 
even  longer,  than  those  with  a  small  liver,  and  we  cannot 
therefore  assert,  that  such  an  enlarged  liver  always  undergoes 
diminution  later  on.  The  pathologo-histological  investigations 
fail  as  yet  to  clearly  elucidate  this  point. 

Thus  the  clinic  presents  the  following  forms  of  cirrhosis  : 
1.  Venotis,  or  cirrhosis  accompanied  by  the  phenomena  of  dis- 
turbed venous  portal  circulation,  in  which  the  liver  is  either 
extremely  dimmished  in  size  (Lcennec  or  atroijldc  cirrhosis^  or 
very  much  enlarged  (hypertrojjliic  venous  cirrhosis,  by  which 
we  mean  a  hypertrophy  of  the  connective  tissue  of  the  liver, 
while  its  glandular  element,  the  hepatic  cells,  are  always  af- 
fected in  cirrhosis).  2.  Hypertroijhic  biliary  cirrhosis,  accom- 
panied by  phenomena  indicating  the  retention  of  the  bile,  and 
3.  Mixed  cirrhosis,  with  symptoms  of  both.  What  form  of 
cirrhosis  does  our  patient  suffer  from?  The  first  impression 
of  the  case,  the  jaundice  and  the  ascites  would  suggest  a  mixed 
cirrhosis ;  but  a  further  investigation  will  lead  us  to  another 
conclusion.  As  evident  from  the  anamnesis,  there  appeared 
repeatedly  in  our  patient  after  a  drinkmg  debauch  and  a  faulty 
diet,  an  attack  of  jaundice  contemporaneously  with  pronounced 
signs  of  a  severe  gastric  catarrh  (dyspepsia,  pains,  vomiting), 
while  a  corrected  diet  and  treatment  caused  their  disappearance 
at  one  and  the  same  time,  so  that  it  (the  jaundice)  undoubtedly 
depends  on  a  catarrhal  condition  of  the  great  biliary  passages. 
It  is  true,  that  this  last,  being  present  for  a  long  time  or  recurring 
frequently,  may  also  spread  over  to  the  small  biliary  ducts  and 
thus  give  rise  to  inflannnation  of  the  connective  tissue  around 
them,  i.  e.  it  may  bring  about  a  condition  of  biliary  cirrhosis, 
but  the  investigation  of  the  given  case  speaks  against  the 
presence  of  this  last,  for  the  jaundice  has  so  rapidly  yielded 
to  the  regimen  and  treatment,  and  particularly  to  the  calomel, 
which  it  usually  fails  to  do  in  biliary  cirrhosis  (the  phenomena 
of  impeded  flow  of  bile  in  this  yield  to  successful  treatment 
much  slower).  Consequently  our  patient  has  venous  cirrhosis 
and  of  the  hypertrophic  form  at  that  (the  liver  is  much  enlarged) 
and  at  the  same  time  also  catarrh  of  the  biliary  passages,  cho- 


—  191  — 

langitis  catarrhalis.  There  are  no  symptoms  of  biliary  calculi. 
The  febrile  condition  of  the  patient,  which  accompanied  the 
jaundice  and  disappeared  with  it  at  the  previous,  as  well  as  at 
the  present,  sojourn  of  the  patient  in  the  clinic,  seems  evidently 
to  be  due  to  the  just  mentioned  cholangitis. 

Treatment.  —  In  view  of  the  discussions  conducted  m  the  pre- 
vious lectures,  it  is,  of  course,  superfluous  for  me  here  to  enter 
into  particular  explanations  regarding  the  use  of  calomel,  of 
Ems,  the  bitters  and  the  stimulating  drops  durmg  the  patient's 
first  sojourn  in  the  clinic,  as  well  as  of  calomel  and  the  stimu- 
lants (together  with  the  diuretics,  as  wine,  the  above-named 
drops  and  the  caffeme)  employed  at  the  present  time.  After 
the  calomel  the  high  temperature  fell  rapidly,  and  for  the 
last  few  days  the  patient  had  no  fever  at  all;  at  the  same 
time  there  took  place  a  pronounced  and  considerable  dimmu- 
tion  of  the  icterous  phenomena  and  the  dyspepsia  disappeared. 
Thanks  to  the  effect  of  the  stimulants  the  pulse  became 
stronger,  but  the  quantity  of  urine  was  not  perceptibly  in- 
creased, while  the  most  threatening  symptom  —  the  ascites, 
so  distressing  to  the  patient,  causing  such  a  disturbance  of 
the  breathing  and  of  circulation  —  became  more  aggravated,  so 
that  in  the  near  future  we  shall  have  to  resort  to  operative  evac- 
uation of  the  peritoneal  cavity.  We  will  agam  administer  to-day 
to  our  patient  some  calomel,  as  he  again  had  a  slight  chill  and 
the  jaundice  has  not  passed  away ;  we  may  also  expect  a  diu- 
retic effect  from  the  calomel.  We  will,  of  course,  continue  the 
wine,  the  above-named  drops  and  the  caffeine  in  increased 
doses.  The  other  diuretics,  as  potassium  acetate  and  the  strong 
ones  (as  adonis  vernalis,  squilla,  etc.)  are  unsuitable  for  the 
present  case  on  account  of  the  diarrhoea  (after  the  calomel 
the  patient's  bowels  move  better,  not  worse).  However,  the 
irresistibly  advancing  ascites  can  hardly  encourage  us  to  hope 
for  a  considerable  effect  of  the  diuretics,  and  the  performance  of 
paracentesis  abdominis  is  inevitable. 

Prognosis.  —  A  fully  developed  venous  cirrhosis  of  the  liver, 
hypertrophic  and  atrophic,  is  incurable  in  the  present  condition 
of  therapy  ;  not  one  of  the  tried  remedies,  among  them  also  the 
iodine    preparations,  realized  oui'  expectations :    the  rarely  ob- 


—  192  — 

served  cases  of  effective  action  of  these  last  remedies  are  very 
likely  due  to  the  fact,  that  these  cases  present  a  mixed  cirrhosis, 
from  alcohol  and  syphilis.  Given  a  relatively  favorable  condi- 
tion of  the  other  organs  and  good  surrounding  circumstances, 
we  may  succeed  in  prolonging  the  patient's  life  by  keeping  in 
good  order  the  digestion,  circulation  and  the  secretion  of  urine 
and  by  operative  evacuation,  at  times,  of  the  peritoneal  cavity. 
The  greatly  disturbed  condition  of  our  patient's  health  gives  us 
but  small  encouragement  for  considerably  prolonging  his  life. 


FROM  THE  LECTURE  OF  MARCH  27,  1892. 

After  the  second  administration  of  calomel  there  was  no 
fever,  the  secretions  are  sufficiently  colored,  the  biliary  pigment 
disappeared  from  the  urine  and  the  sclerotic  became  clear,  but  the 
ascites  progresses  further  and  it  becomes  necessary  to  tap  the 
abdomen  to-day. 

The  further  history  of  the  disease.  —  March  27th  we  obtained 
by  tapping  2500  c.c.  of  limpid,  lemon-colored  fluid  of  a  purely 
transudative  character;  this  afforded  the  patient  considerable 
relief.  Since  April  1st  patient  became  delirious  (the  delirium 
simulates  delirium  potatorum).  At  the  entreaties  of  his 
parents  patient  left  the  clinic,  April  4th,  for  his  home.  At 
the  end  of  the  month  he  again  returned  to  Moscow  and  was 
examined  by  the  clinical  assistant  under  whose  care  he  was 
formerly :  the  delirium  disappeared,  there  is  not  a  trace  of 
jaundice  (the  hemeralopia  and  the  systolic  murmur  disap- 
peared) ;  there  is  enormous  ascites  and  oedema  of  the  legs ; 
by  tapping  3000  c.c.  were  drawn ;  investigation  showed  that 
the  liver  is  just  as  enlarged  and  solid  as  it  was  during  the 
patient's  sojourn  in  the  clinic.  Patient  went  home,  returned 
to  Moscow  at  the  beginning  of  June  again  with  an  enormous 
ascites  and  oedema  of  the  legs.  Again  2500  c.c.  were  drawn, 
he  was  given  sodium  iodide  (20-50  gr.)  and  six  glasses  of 
milk  per  day :  the  result  of  this  treatment  in  two  weeks 
amounted  to  absolutely  nothing,  and  the  accumulated  ascites 
again  necessitated  tapping,  by  which  3000  c.c.  were  drawn. 
Patient  has  gone  home  and  we  have  lost  track  of  him  smce. 


EIGHTH  CASE. 


FROM  THE  LECTURE  OF  DECEMBER  I,   1889, 

The  patient,  a  peasant  eighteen  years  old,  complains  of  pam 
in  the  right  hypochondrium,  of  jaundice  of  one  and  one-half 
years'  duration  and  of  general  weakness. 

Mode  of  living  and  anamnesis.  —  P'or  the  last  ten  years  pa- 
tient has  Lived  constantly  without  intermission  in  Moscow 
(formerly  lived  in  a  village),  all  the  time  in  damp  and  cold 
rooms  (usually  m  a  basement)  ;  does  not  bathe  in  the  river,  takes 
a  weekly  steam-bath.  His  board  is  tolerably  good.  Has  been 
addicted  to  drinking  whiskey  for  the  last  two  years.  His  oc- 
cupation is  that  of  a  shoemaker,  he  works  from  morning  till 
evening,  and,  except  holidays,  is  seldom  out-of-doors. 

Patient  enjoyed  good  health  until  two  years  ago.  Since 
then,  as  I  said  before,  he  began  to  drmk  whiskey ;  six  months 
after  this  he  began  to  feel  pain  in  the  right  side  and  soon  after 
there  appeared  jaundice,  which  is  severely  aggravated  at  the 
present  time.  The  pain  in  the  right  side  is  of  a  double  nature  : 
it  is  either  constant  and  bearable,  or  at  times  very  acute,  lasting- 
three  to  four  hours.  The  attacks  of  this  last  pain  became  more 
frequent  and  more  acute  in  the  course  of  time,  and  have  been 
accompanied  of  late  by  vomiting  (evidently  attacks  of  biliary 
colic).  Patient  grew  thin  and  weak  and  was  admitted  to  our 
clinic  November  27th ;  he  was  never  treated  before.  He  denies 
syphilitic  infection  and  presents  no  signs  of  it. 

Status.  —  Patient  is  of  fair  constitution;  there  is  very  con- 
siderable emaciation  and  jaundice  of  the  skm  and  of  the 
sclerse.  The  appetite  is  good ;  patient  digests  daily  about 
three-fourths  of  a  pound  of  meat,  one-half  pound  of  bread,  two 
eggs  and  two  plates  of  soup,  without  the  least  dyspeptic  signs, 
and  even  begs  for  more  food.      He  is  somewhat  constipated:  the 


—  194  — 

evacuations  are  diy,  fetid  and  apparently  not  at  all  colored 
'by  bile.  The  urine  contains  a  moderate  quantity  of  biliary 
pigment,  but  neither  sugar  nor  albumen ;  to  judge  by  the 
absence  of  color  in  the  secretions,  pointing  to  a  failure  of  the 
bile  to  pass  mto  the  intestines,  we  should  expect  a  darker  dis- 
coloration of  the  urine  (an  mdication  that  the  glandular  ele- 
ments of  the  liver,  the  hepatic  cells,  are  already  affected  and 
hindered  in  their  activity).  The  spleen  is  normal.  The  liver 
is  enlarged,  more  solid  than  normally,  but  of  regular  outlines 
and  smooth,  and  very  sensitive  to  pressure.  The  organs  of 
respiration  and  circulation,  as  well  as  the  nervous  system, 
present  nothing  abnormal :  the  sleep  is  good.     Fever  absent. 

Diagnosis.  —  It  is  evident,  that  our  patient  has  biliary  calculi 
and  a  severe  catarrh  of  the  biliaiy  passages,  —  cholangitis  catar- 
rhalis,  —  to  which  must  be  ascribed  the  pains,  the  failure  of  the 
bile  to  pass  mto  the  mtestines,  its  retention  in  the  liver  (this 
again  caused  the  enlargement  of  the  organ  and  probably  an  im- 
pediment also  of  its  bile-formative  function  and  through  this  of 
its  other  activities  by  compressing  the  hepatic  cells)  and  gen- 
eral jamidice.  But  is  this  all?  Is  there  no  further  affection 
of  the  liver,  and  if  so,  what  is  its  nature?  The  etiology, 
the  course  of  the  disease  and  the  condition  at  present  show, 
that  such  a  further  affection  could  be  an  interstitial  inflammation 
around  the  minute  biliary  ducts  of  the  liver,  that  is,  a  develop- 
ment of  a  hypertrophic  biliary  cirrhosis  (I  shall  not  review  the 
differential  diagnosis  applied  in  the  former  case).  We  can 
neither  deny  nor  affirm  the  presence  of  such  a  cirrhosis  in  tbis 
case ;  on  one  hand  the  disease  has  lasted  for  a  time  long 
enough  for  a  cii'rhosis  to  develop ;  but  on  the  other  hand  it  may 
safely  be  assumed  that  the  observed  symptoms  were  caused  by 
cholangitis  and  biliary  calculi.  We  shall  wait  for  further 
observations. 

We  must  also  wait  with  our  prognosis,  the  more  so  as  it 
always  depends  not  only  on  the  diagnosis  (even  if  clearly 
defined),  but  also  on  the  degree  of  success  of  the  treatment. 
We  cannot,  however,  deny  the  fact,  that  in  view  of  the  patient's 
youth,  his  good  constitution  and  the  healthy  condition  of  his 
other  organs    (outside  of   the   liver),   as   well    as    because  the 


—  195  — 

patient  did  not   subject  himself  to   any  treatment,  his  future 
jjrospects  are  favorable. 

Treatment.  —  We  will  iirst  prescribe  calomel  in  a  slightly 
laxative  dose,  without  inducing  a  diarrhcea ;  later  on  we  may 
employ  a  mineral  water,  namely  Karlsbad,  as  the  patient  is 
inclined  to  be  costive  ;  in  the  former  case,  with  a  tendency  to 
diarrhrea  and  weakness  on  the  part  of  the  patient.  Ems  was 
prescribed.  We  will  also  order  for  the  patient  one  or  probably 
more  warm  baths. 


FROM  THE  LECTURE  OF  DECEMBER   12,   1889. 

Status.  —  December  3d,  4th  and  5th  patient  took  four  one- 
grain  powders  of  calomel  daily  with  the  best  of  results :  the  6th. 
7th  and  8th,  he  had,  once  a  day,  sufficient,  soft,  normally  colored 
stools.  The  9th  we  again  observed  that  the  evacuations  were 
poorly  colored,  and  he  was  therefore  given,  the  day  before 
yesterday  and  yesterday,  four  powders  of  calomel.  The  effect 
was  again  good,  but  there  ajjpeared  slight  salivation,  which  we 
combat  with  the  usual  means  of  rinsing  his  mouth  with  potas- 
sium chlorate  and  pamting  the  gums  with  tra.  gallarum;  out- 
side of  this,  the  patient's  condition  is  entirely  satisfactory :  the 
appetite  is  normal,  the  dyspepsia  disappeared,  the  circulation, 
respiration  and  the  nervous  system  are  in  good  order,  he  feels 
much  stronger ;  the  urine  contams  almost  no  biliary  pigment, 
the  acute  pains  in  the  region  of  the  liver  have  almost  passed 
away,  the  liver  itself  is  almost  insensitive,  but  it  has  diminished, 
though  markedly,  not  much  so,  which  circumstance  speaks  for 
the  presence  of  a  cirrhosis,  though  of  small  extent. 

We  will  certamly  give  no  calomel  to-day,  but  from  to-mor- 
row on  he  shall  take  Karlsbad ;  later  on,  in  case  of  necessity, 
we  will  again  resort  to  calomel. 

The  further  Jiistory  of  the  disease.  —  Patient  drank  four  half- 
glassfuls  of  Karlsbad  water  daily  until  January  2d,  when  he 
left  the  clinic ;  we  did  not  administer  calomel  any  more.  By 
the  time  he  left  not  only  were  the  evacuations  all  the  time 
entirely  colored  and  the  urine  always  limpid,  containing  no 
biliary  pigment,   but   the  general  jaundice  had  almost   disap- 


—  196  — 

peared,  the  patient  gained  eleven  pounds  in  weight  (he 
'weighed  121  pounds  on  admission,  his  weight  when  he  left 
was  132  pounds),  and  gathered  strength;  the  liver  is  entirely 
msensitive  to  pressure,  but  it  remained  of  a  rather  more  en- 
larged size  than  it  would  be  normally. 

At  our  insistent  advice  patient  gave  up  drinking,  and  about 
six  months  later  he  appeared  before  our  clinical  assistant  in  the 
same  satisfactory  condition,  as  he  enjoyed  when  leaving  our 
clinic. 

Thus  the  dxth  case  presents  biliary  calculi  and  cholangitis, 
the  sevew^A  — hypertrophic  venous  cirrhosis  and  cholangitis,  the 
eighth  — hi\idi,v J  calculi,  cholangitis  and  a  slight  hypertrophic 
biliary  cirrhosis.  In  my  article  on  calomel  the  reader  will  find 
not  only  a  fully  characteristic,  but  also  a  very  severe  case  of 
hypertrophic  biliary  cirrhosis,  which  however,  terminated  favor- 
ably. 


NINTH  CASE. 


FROM  THE  LECTURE  OF  NOVEMBER  16,  1890. 

The  patient,  a  peasant  twenty-nine  years  old,  was  admitted 
to  the  clinic  a  week  ago,  complaming  that  the  abdomen  "  swells 
up,"  and  that  he  is  weak ;  he  added,  that  he  was  once  before 
taken  care  of  in  the  hospital,  where  he  was  told,  that  his 
disease  is  called  echinococcus  of  the  liver. 

Mode  of  living  and  anamnesis. — -During  the  last  year,  on 
account  of  his  illness,  patient  has  been  liviug  m  a  village  of 
the  Ryazan  Government,  in  a  healthy  locality ;  formerly  he 
lived  alternately  in  both  Moscow  and  in  the  village,  under  the 
ordinary  conditions  of  life  of  a  peasant  and  of  a  workingman. 
While  in  the  country  his  occupations  are  those  of  a  peasant; 
in  the  city  he  is  a  joiner.  He  drank  but  little  whiskey.  He 
is  married  and  has  several  children ;    his  wife  never  aborted. 

Patient  comes  from  a  healthy  family  and  until  the  last  four 
years  enjoyed  good  health.  Four  years  ago  he  began  to  notice 
a   swelling   in   the  right  hypochondrium,  which  was  painless, 

but  kept  constantly  growing,  until  he  was  finally  so  much 
hindered  in  his  occupation  and  movements,  that  three  years 
ago  he  entered  the  hospital,  where  they  performed  an  oper- 
ation, drew  the  fluid  and  told  him  (he  has  a  distinct  recol- 
lection of  the  name)  that  his  disease  was  called  echino- 
coccus of  the  liver.  He  remained  in  the  hospital  for  seven 
months  and  left  without  a  trace  of  the  former  swelling.  The 
next  year  and  a  half  he  enjoyed  good  health;  but  about  a 
year  ago  he  again  observed  a  swelling  in  the  right  hypochon- 
drium, somewhat  painful  at  that  time,  which  also  began  to  grow 
in  size  and  interfered  with  his  work ;  at  the  same  time  patient 
began  to  grow  thin  and  weak.  Two  weeks  ago  the  swelling 
suddenly    diminished,    and    almost    disappeared,    but    at    the 


—  198  — 

same  time  tlie  abdomen  began  to  swell  rapidly,  it  l)ecame  pain- 
ful and  there  appeared  chills,  fever  and  diarrhoea;  he  had  some 
ten  liquid  stools  daily ;  in  the  course  of  two  days  the  fever 
and  the  diarrhcea  passed,  and  soon  the  abdominal  pains  quieted 
down,  but  the  abdomen  began  to  increase  m  size ;  the  patient 
then  came  to  Moscow  and  entered  our  clmic. 

Status  at  the  day  of  admission.  —  The  appetite  is  good,  but  the 
patient  eats  little  at  a  time ;  otherwise  he  feels  uncomfortable,  as 
respiration  grows  difficult.  Outside  of  this  there  are  no  dyspep- 
tic phenomena;  stools  regular.  The  quantity  of  urine  is  1100 
c.  c,  containing  neither  albumen  nor  sugar.  Tliere  is  a  pro- 
nounced ascites  of  considerable  size  (distinct  fluctuation)  :  the 
circumference  of  the  abdomen  at  the  level  of  the  umbilicus 
is  98  c.  m.,  the  distance  between  the  anterior  superior  spine  of 
the  ileum  and  the  umbilicus  is  28  c.  m.  The  tension  of  the 
stretched  abdominal  walls  does  not  permit  of  palpatmg  the  liver. 
There  are  neither  pains  nor  sensitiveness  on  pressure  m  the  ab- 
domen. The  diaphragm  is  very  much  raised.  There  is  dysp- 
noea on  moving  around,  breathing  while  in  a  state  of  rest  is  26 ; 
pulse  76,  regular,  but  weak  ;  outside  of  this  there  is  nothing  ab- 
normal in  the  organs  of  respiration  and  cu-culation,  as  well  as  in 
the  nervous  system,  except  that  the  sleep  is  not  sound  on  ac- 
count of  the  large  size  of  the  abdomen,  which  hinders  motion 
and  freedom  of  abdominal  breathing.  Fever  absent.  The  pa- 
tient, as  I  said  before,  has  grown  weak  and  thm.  He  denies 
syphilitic  infection,  nor  are  there  any  indications  of  it. 

The  patient  was  placed  amidst  normal  conditions  of  life,  the 
abdomen  was  protected  bj'  flannel,  and  he  was  given  internally 
potassium  acetate  as  a  diuretic,  and  six  to  eight  tablespoonfuls 
of  port  wine  per  day. 

Status  to-day.  —  Patient  feels  somewhat  better  :  his  breathmg 
became  freer,  his  strength  mcreases,  and  the  sleep  is  also 
better ;  the  dimensions  of  the  abdomen  do  not  present  any 
marked  decrease ;  the  quantity  of  urine  has  almost  doubled 
(2000  c.  c). 

Diagnosis.  —  It  is  evident,  that  within  the  last  year  there  agam 
formed  ui  our  patient  an  echinococcus  bladder,  which  burst 
into  the  peritoneal  cavity,  and  probably,  at  the  same  time,  also 


—  199  — 

into  the  intestines.  The  absence  of  severe  pains  and  of  fever  for 
the  time  —  one  year —  the  disease  lasted  speaks  agamst  its  being 
an  abscess  of  the  liver :  the  pains  were  very  trifling,  while  there 
was  no  fever  at  all ;  the  appetite  remained  always  good,  but  the 
patient  could  not  eat  as  much  as  he  desired,  in  view  of  the  pres- 
sure exerted  by  the  enlarged  liver  on  the  stomach,  and  he  there- 
fore grew  thin  and  weak.  Tlie  emptying  of  the  contents  of  the 
echinococcus  bladder  into  the  peritoneal  cavity  caused  a  slight 
peritonitis,  which  soon  passed,  but  it  produced  ascites. 

Treatment.  —  Accumulations  m  the  peritoneal  cavity  do  not 
in  the  majority  of  cases  yield  to  internal  treatment,  but  require 
operative  interference  —  either  radical,  or,  in  case  of  impossi- 
bility, palliative,  namely,  the  drawing  off  of  the  fluid.  Fortu- 
nately m  the  present  —  very  rare  —  case,  the  condition  is  more 
favorable.  The  phenomena  of  peritonitis  were  so  trifling  (the 
pains  were  not  of  an  acute  character,  there  was  no  vomiting, 
the  fever  was  slight),  and  passed  away  so  rapidly,  that  we  hope 
for  a  favorable,  hardly  at  all  changed  condition  of  the  perito- 
neum, and  consequently  may  expect  a  possible  absorption  of 
the  accumulated  fluid.  That  part  of  the  liver,  which  escaped 
the  invasion  of  the  echmococcus,  performs  its  functions  normally, 
as  evidenced  by  the  regular  digestion  and  the  fact,  that  the  in- 
testinal evacuations  are  well  colored  by  the  bile ;  consequently 
we  may  hope  for  a  sufliciently  free  circulation  in  the  liver,  and 
therefore  also  in  the  portal  system.  The  appetite  is  good,  the 
stomach,  intestines,  kidneys  and  the  other  organs  are  healthy. 

All  these  circumstances  encourage  us  to  hope  for  the  possible 
absorption  of  the  fluid  accumulated  in  the  peritoneal  cavity ;  it 
would  therefore  be  erroneous  to  resort  at  once  to  the  operation, 
befo're  first  attempting  internal  remedies. 

Having  surrounded  our  patient  by  correct  hygienic  conditions, 
we  prescribed  a  diuretic  to  encourage  the  absorption  of  the  accu- 
mulated fluid.  Sudorific  treatment,  as,  for  example,  warm  baths, 
pilocarpine,  would  tend  to  weaken  the  heart's  action  and  would 
thus,  instead  of  encoiiraging  absorption,  rather  add  to  the  accu- 
mulation ;  not  to  speak  of  the  fact,  that  in  the  patient's  condi- 
tion, with  his  difficultly  performed  respiration  and  circulation, 
such  treatment  would  become  dangerous ;  while  treatment  by 


—  200  — 

the  aid  of  laxatives  would  tend  to  disturb  digestion  and  nutri- 
tion, thus  aggravating,  mstead  of  improving,  the  patient's  con- 
dition. In  prescribing  the  diuretic  treatment,  we  aimed  at  the 
two  principal  agencies  of  urinary  secretion  —  the  heart  and  the 
kidneys  :  for  the  first  we  gave  the  wine,  as  the  patient's  pulse 
was  weak,  for  the  second  potassium  acetate  (strong  diuretics, 
as  adonis  vernalis,  squilla,  etc.,  would  disturb  digestion,  and 
weaken  the  patient),  half  a  drachm  per  day,  thus:  IJ.  —  Potas. 
acetatis  3j,  aquse  petroselini  jvj,  for  two  days,  in  tablespoonful 
doses ;  this  was  given  during  four  days,  after  which  it  was 
stopped  for  two  days. 

The  condition  of  the  patient  is  apparently  improving,  and 
the  plan  of  treatment  will  therefore  remain  as  heretofore ;  but 
as  the  dose  of  the  potassium  acetate  —  3ss.  for  a  whole  day — is 
rather  small,  and  the  patient  bears  it  well,  we  will  increase  the 
dose  to  one  drachm  per  day:  I^.  —  Pot.  acetatis  3ij,  aquae  petro- 
selini jij,  for  two  days,  in  tablespoonful  doses.  As  before,  we  will 
interrupt  the  administration  of  the  drug  after  four  days  for  two 
days :  thus  the  power  of  digestion  will  more  certainly  be 
preserved  in  a  good  condition,  nor  will  there  be  formed  a  habit 
for  the  drug,  which  would  bring  on  a  weakened  effect  of  this 
last  on  the  patient. 


FROM  THE  LECTURE  OF  DECEMBER   12,   1590. 

Status.  —  Patient  declares  that  he  feels  entirely  well.  As 
a  matter  of  fact,  his  appetite  is  good,  digestion  regular,  the 
quantity  of  urine  2000  (it  even  reached  3000),  the  spleen 
is  normal,  the  abdomen  is  of  normal  dimensions,  its  circum- 
ference is  72.5  cm.,  the  distance  from  the  superior  spine 
of  the  ileum  to  the  umbilicus  is  15  cm.,  the  diaphragm  is  at 
its  normal  position,  there  are  no  traces  of  any  former  accumula- 
tion, the  respiration,  circulation  and  the  nervous  system  are 
in  a  normal  condition,  the  patient  became  stout  and  quite 
strong.  The  liver  is  entirely  insensitive  and  is  markedly 
enlarged  in  its  left  lobe  ;  nothing  abnormal  to  be  noted  in  the 
right    one.      Echinococcus  bladders  are  most  frequently  found 


—  201  — 

in  the  right  lobe  of  the  liver:  limited  functional  activity  of 
this  portion  of  the  organ  may  bring  on  an  increase  in  the  func- 
tional activity  and  hypertrophy  of  the  left  lobe. 

The  patient  was  told  of  the  possible  failure  of  a  fresh  forma- 
tion of  the  swellmg,  but  in  case  of  its  reappearance  he  is  to 
apply  at  once  for  medical  aid. 


TENTH    CASE. 


FEBRUARY,   1890. 

The  patient  is  thirty-three  years  old  and  was  admitted  to  our 
clinic  February  3,  1890,  complainmg  of  pams  in  the  right  side 
and  of  difficulty  in  breathing. 

3Iode  of  living  and  anamnesis.  —  Patient  is  a  resident  of 
Moscow,  inhabits  fair  lodgings,  the  water-closet  is  cold.  Fre- 
quents public  baths ;  is  subject  to  sweating-.  His  occupation 
is  that  of  a  foreman  at  a  railroad  station  :  he  is  a  bookkeeper 
and  superintends  the  reception  and  delivery  of  goods ;  this 
occupation  is  not  a  fatiguing  one.  He  is  married,  but  his  wife 
had  no  children.  Has  strongly  abused  alcohol  since  his  twenty- 
third  year,  but  since  his  illness,  from  July  of  last  year,  he  gave 
up  drinking  altogether. 

In  December  1877,  patient  became  infected  with  syphilis,  and 
was  treated  for  two  months  with  potassium  iodide,  and  one 
year  later  he  entered  the  hospital  m  St.  Petersburg,  where  he 
was  treated  with  mercurial  inunction,  and  also  with  potassium 
iodide.  Since  then,  in  the  course  of  the  next  ten  years,  up  to 
the  summer  of  1889,  he  observed  nothing  to  require  a  resort 
to  treatment.  During  the  summer  of  1889  he  began  to  ex- 
perience heaviness  in  the  abdomen  and  d3'spnoea,  and  soon  after 
that  pains  in  the  right  hypochondrium  aggravated  at  night- 
time and  on  movmg  around.  The  patient  left  off  drinking 
abruptly ;  after  this  the  appetite  grew  worse,  and  he  began  to 
grow  thm  and  weak,  the  dyspnoea  increased,  and  he  became 
costive.  At  the  advice  of  his  physician,  w^ho  already  at  that 
time  detected  a  considerable  enlargement  of  the  liver,  he  drank, 
during  one  month,  Yessentucki  waters  No.  17  and  took  laxa- 
tives, but  without  any  avail.  Since  September  1889,  patient 
was  treated  during  three  weeks  in  the  hospital  with  mercurial 


—  203  — 

inunctions  —  altogether  about  ten  times  —  and  with  potassium 
iodide  internally,  and  later  on  took  the  same,  without  increasmg 
the  dose,  at  home  for  another  three  weeks ;  the  pain  improved 
for  some  time.  From  that  time  on  until  his  admission  to  the 
clinic  the  patient  was  not  treated,  and  his  condition  continued 
growmg  woi'se. 

Status  on  February  Sd.  —  Patient  is  of  a  strong  constitu- 
tion. Appetite  fair,  but  patient  eats  little,  as  the  feeling  of 
heaviness  in  the  abdomen  becomes  aggravated  after  a  meal. 
There  is  no  dyspepsia.  He  is  very  costive.  Urine  shows  ab- 
sence of  albumen  and  sugar.  The  abdomen  is  enlarged,  there  is 
slight  ascites.  The  spleen  is  somewhat  enlarged ;  the  liver 
very  much  so :  on  percussion  the  superior  border  is  higher  than 
normally,  while  the  free  border  is  palpated  at  a  distance  greater 
than  the  width  of  the  palm  below  the  costal  edge  ;  it  is  moreover 
not  sharp,  but  dull  to  the  touch  ;  there  are  no  other  alterations 
in  the  shape  of  the  liver ;  it  is  more  solid  than  normally,  and 
besides,  it  is  sensitive  to  pressure  all  over ;  the  mobility  of  the 
liver  in  respiratory  movements  is  of  slight  extent.  There  was 
no  jaundice  before,  nor-  is  there  any  at  present.  The  heart  is 
displaced  upward,  its  tones  are  clear,  the  pulse  —  66  —  is  weak, 
there  is  some  dyspnoea.  The  organs  of  respiration  present 
nothing  abnormal ;  there  is  no  fever.  The  patient  is  very  weak 
and  thin.  The  impeded  breathing  and  the  nightly  exacerbation 
of  pains  on  the  side  of  the  liver  prevent  sound  sleep.  The 
head,  and  especially  the  occiput,  aches  while  patient  is  consti- 
pated, but  the  pam  is  relieved  by  a  good  evacuation  of  the 
bowels. 

Diagnosis.  —  If  certam  persons,  who  are  habituated  to  drink- 
ing -strong  alcoholic  drinks  for  a  long  time,  leave  off  the  habit 
abruptly,  then  as  a  consequence  there  appears  a  whole  series  of 
disturbances :  the  appetite  is  impaired,  the  patient  has  either 
constipation  or  diarrhtjea  instead  of  the  former  regular  evacua. 
tion  of  the  bowels,  the  pulse  grows  weak,  there  appears 
dyspnoea,  the  patient  grows  thin,  sleeps  badly  and  weakens 
physically  and  mentally.  As  seen  from  the  anamnesis,  some  of 
the  disturbances  observed  in  our  patient  are  undoubtedly  of 
such  an  origin,  while  the  others  depend  on  an  evident  disease 


—  204  — 

of  the  liver :  this  last  is  very  much  enlarged  and  sensitive,  and 
•the  ascites  and  the  enlarged  spleen  speak  of  impeded  circulation 
in  the  portal  system. 

What  hepatic  disease  is  to  be  found  in  this  case?  The 
anamnesis,  and  partly  the  symptoms,  as  the  regular  aggra- 
vation of  the  hepatic  pains  at  night,  pomt  to  syphilis  as  the 
immediate  cause  of  the  affection  of  the  liver ;  we  cannot  at  the 
same  time  deny  the  influence  of  a  prolonged  abuse  of  alcohol. 
With  such  data  on  hand  and  in  view  of  all  that  we  said.^  while 
discussmg  the  foregoing  cases,  regarding  the  diagnosis  of  dis- 
eases of  the  liver  in  general  and  their  differential  diagnosis  in 
particular,  there  seems  to  be  no  reason  to  further  discuss  the 
exclusion  of  other  affections  of  the  liver  in  this  case.  Of  the 
two  affections,  the  presence  of  which  is  possibly  indicated  by 
the  anamnesis,  which  is  more  probable,  the  syphilitic  or  the 
alcoholic  ?  The  data  which  speak  for  syphilis  of  the  liver  are 
incontestable :  the  liver  is  pamful,  which  is  only  to  a  slight 
degree  the  case  in  alcoholic  affection  of  the  org^an ;  the  pains  are 
aggravated  at  night-time,  specific  treatment  relieves  the  pains, 
and  the  liver  is  very  much  enlarged  (this  again  is  but  to  a 
slight  extent  the  case  in  the  alcoholic  affection  of  the  liver)  ; 
there  are  no  dii'ect  indications  of  the  existence  also  of  an 
alcoholic  affection  of  the  liver  (as  impeded  portal  venous  circula- 
tion is  also  peculiar  to  syphilis  of  the  liver),  but  we  simply  can 
not  deny  the  possibility  of  its  existence  in  the  given  case. 

What  is  the  nature  of  the  sj^Dhilitic  affection  in  the  given 
case?  There  is*  first  of  all  an  mdication  of  a  syphilitic  perihe- 
patitis, namely :  tenderness  of  the  liver,  the  aggravation  of  pains 
at  night-time,  and  the  restriction  of  the  respiratory  movements 
of  this  organ  ;  however,  the  value  of  this  last  symptom  is  les- 
sened by  the  fact,  that  m  the  presence  of  an  enlarged  liver  and 
of  tension  of  the  abdominal  walls,  the  respnatory  movements 
of  this  organ  are  liable  to  be  less  free  than  under  normal  con- 
ditions, even  if  we  exclude  the  possible  adhesions  due  to  the 
perihepatitis.  There  are  no  iiidications  of  any  considerable 
gummatous  swellmg,  as  the  surface  of  t^ie  liver  is  smooth. 
There  remain,  therefore,  out  of  the  number  of  various  sj'^philitic 
affections   of   the   liver,  minute  disseminated  gummatous  new 


—  205  — 

formations,  disseminated  interstitial  hepatitis  and  its  result  in 
the  form  of  cirrhosis  of  the  liver,  to  which  in  this  case  we  must 
ascribe  the  enlargement  of  this  organ.  Which  of  these  just 
mentioned  aif ections  prevails  is  rather  diificult  to  say :  the 
symptoms  of  impeded  portal  venous  circulation  pomt  to  an 
already  existing  cirrhosis. 

Prognosis.  —  The  pams  in  the  liver,  caused  by  the  perihepa- 
titis, yield  readily  to  specific  treatment,  especially  to  the  iodide 
preparations.  But  the  prognosis  is  most  favorable,  when  there 
are  gummatous  swellmgs,  even  if  considerable,  but  without  af- 
fections of  other  parts  of  the  organ ;  in  such  a  case  complete 
cure  is  possible.  Much  worse  is  the  prognosis  in  diffuse  mter- 
stitial  hepatitis  and  in  the  cirrhosis  of  the  liver  resulting  there- 
from :  here  the  success  of  the  treatment  is  liable  to  be  rather 
insignificant  and  of  short  duration ;  if  aggravated,  after  a  tem- 
porary improvement,  the  disease  yields  with  greater  difficulty  to 
treatment  and  usually  termmates  in  death.  The  same  process 
evidently  takes  place  in  the  liver,  as  in  the  nervous  system  (and 
probably  also  in  the  other  organs),  namely,  an  outspoken  syphilit- 
ic affection  (gummatous?  —  as  in  the  nervous  system,  in  case  of 
lues  of  the  brain  and  spmal  cord),  which  yields  completely  to 
specific  treatment,  and  also  such,  in  which  the  connection  with 
syphilis  is  apparent  (as  shown  from  the  statistics  of  the  affections 
of  the  nervous  system,  progressive  paralysis  and  tabes  dorsalis), 
but  in  which  the  specific  treatment  falls  short  of  havmg  this  ef- 
ffect.  The  prospects,  as  regards  the  termuiation  of  the  disease  in 
our  patient,  who  presents  such  evident  symptoms  of  affection  of 
the  ivhole  liver  and  together  with  this  also  symptoms  of  an 
already  progressive  impediment  in  the  portal  venous  circulation, 
are  certamly  not  favorable  ;  but  as  the  patient  was  never  sub- 
jected to  a  continuous,  sufficiently  persistent  and  intensive 
treatment,  the  last  word  in  the  prognosis  will  depend  on  the 
treatment. 

Treatment.  —  Having  surrounded  the  patient  by  regular  hy- 
gienic conditions,  we  will  prescribe  for  him  some  strong  wine, 
as  the  pulse  is  weak  and  the  patient  at  the  present  more  than 
at  any  other  time  is  m  need  of  his  habitual  stimulus :  for  the 
constipation,  —  watery  clysters,  and  for  the  principal  affection 


—    206   — 

specific  treatment,  at  the  beginning  iodine  in  the  form  of  sodium 
•iodide.  We  will  give  him  the  iodide,  and  not  mercury,  first, 
because  m  the  last  stage  of  syphilis,  which,  as  seen  from  the 
anamnesis  and  from  the  very  nature  of  the  sj^philitic  affection, 
our  patient  is  passing  through,  iodide  is  more  applicable ;  and 
secondly,  because  the  patient's  health  has  become  greatly  im- 
paired, and  the  mercurial  treatment  by  itself  is  more  liable  to 
weaken,  than  the  treatment  with  iodides ;  and  thirdly,  because 
the  syphilitic  pains  particularly  yield  readily  and  rapidly  to  the 
iodine  treatment.  We  will  administer  the  sodium  iodide  in  an 
alkaline  mineral  water,  as  in  Vichy,  one  and  one-half  glasses  per 
day  because  the  iodides  are  better  borne  by  the  organism  when 
dissolved  in  it,  and  also  because  our  patient's  urine  is  red,  very 
acid  and  saturated  with  uric  acid  salts.  In  such  cases  as  the 
present  one,  the  iodine  preparations  are  to  be  administered,  as 
experience  teaches,  in  constantly  increasmg  and  generally  large 
quantities.  We  will  be  guided  in  our  further  treatment  hj  the 
results  of  the  iodine  treatment. 

Status  on  February  28th.  —  The  patient  took  sodium  iodide 
as  follows : 

February  4th,  20  gr.  ;  February  5th  and  6th,  30  gr.  each  day ; 
February  7th  to  10th,  -tO  gr.  each  day;  February  11th  to  loth. 
50  gr.  each  day ;  February  16th  to  20th,  60  gr.  each  day ;  Febru- 
ary 21st  to  28th,  70  gr.  each  day. 

The  iodide  was  administered  in  solution  (3ij  in  fvj  aquse 
dest.)  in  tablespoonful  doses,  with  the  addition  in  the  begmning 
of  a  small  quantity  of  Yichy-Celestins,  and  later  —  in  view  of 
a  beginning  looseness  of  the  bowels  —  of  Ems-Kesselbrunnen, 
about  one  and  one-half  glass  per  day. 

To-da}'  the  patient  announces  that  he  feels  so  well,  that,  ap- 
prehending the  possible  loss  of  his  situation,  he  mtends  to  leave 
the  clinic.  His  condition  is  as  follows :  the  appetite  is  very 
good,  bowels  move  regularly  (the  clysters  were  necessary  only 
during  the  first  daj^s  of  the  patient's  sojourn  at  the  clmic),  the 
quantity  of  urine  is  greater,  it  is  limpid  and  not  red,  all  the 
pains  disappeared,  the  pulse  is  better,  the  sleep  is  good,  patient 
gathered  considerable  strength,  the  liver  is  entirely  painless, 
but  it  has  dimmished  in  size  but  very  little,  and  so  did  the 
ascites. 


—  207  — 

The  patient  was  inforined  of  the  seriousness  of  his  condition ; 
he  was  told,  that,  although  the  pams  have  disappeared,  the  ap- 
petite and  sleep  improved  and  he  became  stronger  physically, 
still  the  most  important  and  the  most  dangerous  symptoms  — • 
namely,  the  enlargement  of  the  liver  and  the  ascites,  have  not 
yielded  markedly  to  the  iodide  treatment;  that  the  treatment 
must  be  continued  persistentl3%  and  that  at  present  he  must  be- 
gin the  mercurial  treatment ;  he  was  made  to  understand,  that 
a  correct  employment  of  such  a  powerful  drug  as  mercury,  to 
avoid  any  risk  of  harm,  is  onl}-  possible  under  immediate  medi- 
cal supervision  and  under  suitable  circumstances,  namely,  m  the 
Hospital,  and  that  any  postponement  of  this  treatment  will 
exert  a  dangerous  tendency  as  regards  a  favorable  termination 
of  the  disease.  The  patient  insisted  that  he  must  return  to  his 
occupation  and  that  he  would  try  to  be  treated  at  home ;  he  left 
the  cluiic  the  next  day. 

The  further  hhtory  of  the  disease.  —  Patient  continued  taking 
sodium  iodide  during  March  in  small  quantities  and  irregularly, 
but  up  to  June  he  felt  almost  as  well  as  he  did  on  leaving  the 
clinic.  Since  then  there  reappeared  the  severe  pains  in  the 
right  side,  and  the  patient  began  to  take  calomel,  four  powders 
a  day  (the  dose  is  unknown ;  he  had  slight  looseness  of  the 
bowels)  in  the  following  manner :  one  week  calomel,  the  next 
week  none ;  during  this  time  rinsed  his  mouth  with  pot.  chlor. 
and  his  gums  were  not  affected.  Tliis  treatment  was  continued 
through  June,  July  and  August.  The  patient  improved  some- 
what and  his  tolerable  condition  contmued  up  to  February  1891, 
when  the  right  side  became  agam  painful,  the  abdomen  began 
to  enlarge  rapidly,  and  later  on  the  legs  began  to  swell.  Feb- 
ruary 18th  patient  again  entered  our  clinic. 

Status  on  February  ISth.  —  Appetite  very  poor;  there  is 
properly  speaking  no  dyspepsia,  but  the  nausea  and  vomiting- 
are  rather  of  ursemic  nature,  as  they  take  place  not  after  a  meal, 
but  in  connection  with  heavmess  in  the  head  and  with  paui. 
There  is  at  times  constipation,  at  other  times  diarrhoea.  The 
urine  contains  a  considerable  quantity  of  albumen,  and  also 
some  cylmders  —  hyaline  and  granular ;  the  quantity  of  urine 
in  twenty-four  hours  is  500  c.  c.     The  ascites  is  great,  while  the 


—  208  — 

oedema  of  the  legs  extends  up  to  their  middle ;  the  spleen  does 
•not  admit  of  palpation.  The  liver  is  in  the  same  condition  in 
which  it  was  a  year  ago,  the  tenderness  on  pressure  is  not  con- 
siderable. The  heart  is  displaced  upward,  the  pulse  is  96  and 
weak.  The  respiratory  organs  are  normal.  Fever  is  absent. 
The  sleep  is  very  poor.  The  patient  became  very  much  ema- 
ciated and  weak. 

Treatment.  —  Correct  hygienic  conditions,  wine,  and  an  injec- 
tion when  necessary.  As  the  patient  has  been  treated  for  a 
long  time  with  mercury,  and  has  not  taken  any  iodide  for  almost 
a  year,  we  prescribed  for  him  sodium  iodide,  at  the  beginning  in 
a  small  quantity  of  Ems  water,  and  later  on  in  boiling  milk. 
As  the  tendency  to  diarrhoea  increased  while  the  iodide  was 
being  administered,  we  also  gave  at  the  same  time  ten  to  twenty 
drops  of  tra.  coto  four  times  a  day,  which  enabled  us  to  con- 
tinue the  administration  of  the  iodide  for  six  weeks,  and  to  in- 
crease the  dosage  to  ninety  gr.  per  day  ;  but  there  was  no  im- 
provement: February  27th  we  had  to  di'aw  3000  c.  c.  of 
fluid  of  a  purely  transudative  character  from  the  peritoneal 
cavity.  Smce  March  19th  we  added  to  the  sodium  iodide  also 
mercurial  inunction  —  a  half-drachm  of  mercurial  ointment  per 
day.  March  25th,  however,  we  were  again  compelled  to  draw 
3,000  c.  c.  By  the  end  of  March  the  specific  treatment  with 
the  iodide,  as  well  as  with  the  mercury,  was  discontinued  (we 
made  altogether  about  ten  inunctions)  and  we  contmued  to 
strengthen  him  as  much  as  possible.  April  12th  patiei^t  left 
the  clinic  in  the  same  condition  in  which  he  was  admitted ;  the 
accumulation  in  abdominal  cavity,  after  the  last  tapping,  did 
not  as  yet  reach  the  former  dimensions,  but  it  continued  on  the 
increase. 


RHEUMATISM  AND  GOUT. 


ELEVENTH   CASE. 


LECTURE  OF  NOVEMBER  29,   1889. 

The  patient,  a  peasant  water-carrier,  twenty-five  years  old, 
was  admitted  to  the  clinic,  complaining  of  severe  pains  m  the 
articulations,  loss  of  appetite  and  weakness. 

Mode  of  living  and  anamnesis.  —  Patient  lives  in  ^Moscow. 
His  lodgings  are  very  warm,  the  water-closet  cold.  Goes 
often  to  public  bathing  house  and  drinks  a  great  deal  of  hot 
tea ;  is  very  much  subject  to  sweating.  Is  a  moderate  whiskey 
drinker.  His  food  is  that  of  an  ordinary  workingman.  He 
works  hard  and  is  very  much  fatigued  at  the  close  of  the  day. 
He  is  smgle. 

Until  the  present  sickness  the  patient  always  enjoj^ed  good 
health,  except  that  he  suffered  with  headaches,  which  appeared 
at  the  hot  season  of  the  year  during  field  labor,  and  which 
passed  away  accompanied  by  nasal  hgemorrhages.  A  week 
ago,  November  21st,  the  patient  became  strongly  chilled,  and 
in  the  evening  he  experienced  chills,  fever  and  pain  in  the 
articulations;  he  took  no  tieatment,  and  until  his  admission 
to  the  clinic,  November  27th,  he  grew  worse  and  worse.  No- 
vember 27th  and  28th  the  patient  was  given  seven  ten-grain 
powders  of  sodium  salycilate  in  Ems-Kesselbrunnen  water, 
after  which  he  had  considerable  tinnitus  aurium,  but  the  pains 
were  very  much  relieved  and  he  was  not  given  any  more  of  the 
salycilate.  The  painful  articulations  were  rubbed  with  warm 
olive  oil  and  wrapped  in  cotton. 

Status.  —  The  appetite  has  reappeared,  there  is  no  dyspepsia, 
stool  regular.  The  urine,  formerly  red  and  quite  saturated, 
became  limpid ;  it  contains  neither  sugar  nor  albumen.     The 


—  210  — 

liver  and  spleen  are  in  a  normal  condition,  as  well  as  the  organs 
of  respiration,  circulation  and  the  nervous  system.  His  tem- 
perature on  admission  was  38.2°  R.  (100.7°  i^.)  ;  at  present  it  is 
36.8°  R.  (98.2°  F.').  When  admitted  patient  perspired  freely, 
now  he  perspires  but  little.  On  admission,  all  the  joints  (except 
that  of  the  hip)  of  the  lower  extremities  were  affected,  also  both 
the  elbow  jouits :  the  pains  were  acute  and  the  patient  avoided 
any  movement ;  a  slight  swelling  onlj^  was  noticed  at  the  articu- 
lations of  the  knees.  At  the  present  time  all  the  pains  are  con- 
siderably relieved,  but  they  are  felt  as  yet  to  some  extent  where- 
ever  they  were  before ;  the  swelling  of  the  knee-jomts  disap- 
peared. The  noise  in  the  ears  continues  as  yet,  but  to  a  very 
much  lesser  degree. 

Biagyiosis.  —  It  is  evident  that  our  patient  suffers  from  acute 
articular  rheumatism.  This  is  shown,  outside  of  the  charac- 
teristic picture  of  the  disease,  by  the  acute  beginning  of  this 
last  in  an  organism  previously  healthy,  in  the  presence  of  the 
equally  peculiar  in  this  disease  predisposmg  conditions,  as  a  warm 
lodging,  frequent  hot  baths,  hot  tea,  proclivity  to  perspiration, 
constant  fatigue  from  physical  labor,  and  finally  a  cold,  and 
also  by  the  decided  effect  of  the  salycilate  of  sodium,  which 
serves  in  acute  articular  rheumatism  as  hardly  less  of  a  specific 
remedy,  than  quinme  does  in  malaria.  We  know  of  no  other 
disease,  that  would  call  out  so  suddenly  such  an  agglomerate 
of  symptoms  and  which  would  so  rapidlj^  yield  to  the  salycilate 
of  sodium. 

Prognosis,  —  The  disease  is  slight  and  is  already  passing 
away,  but  it  is  very  liable  to  return,  especially  under  the  cir- 
cumstances surrounding  our  patient  and  his  mode  of  living. 

Treatment.  —  The  patient  was  given  the  most  reliable  remedy 
against  acute  articular  rheumatism,  namely,  sodium  salycilate : 
you  have  seen  its  effects.  I  usually  administer  sodium  salyci- 
late in  a  small  quantity  (in  one  or  two  glasses  per  day)  of  the 
alkaline  water  Ems-Kesselbrunnen,  or,  to  persons  of  a  strong 
constitution  and  with  good  nutrition  and  who  are,  moreover, 
mclined  to  gout,  m  some  Vichy-Celestins,  because  this  remedy 
is  borne,  if  thus  admmistered,  in  the  best  manner.  The  pa- 
tients, who  dislike  the  unpleasant  taste  of  sodium  salycilate. 


—  211  — 

may  take  this  last  in  cachets  and  wash  them  down  with  an 
alkaline  water.  For  acute  articular  rheumatism  I  never  fail  to 
give  sodium  salycilate  until  tiunitus  aurium  is  produced  (just 
as  in  the  ease  of  quinine  for  malaria),  at  times  quite  strong,  at 
other  times,  in  very  severe  cases,  till  very  pronounced,  watch- 
ing of  course  carefully  the  action  of  the  heart,  in  which  large 
doses  of  salycilate  of  sodium,  especially  if  given  for  a  long  time 
without  an  intermission,  may  induce  a  condition  of  collapse. 
Experience  taught  me  to  regard  such  a  mode  of  employing 
sodium  salycilate  in  acute  articular  rheumatism  (just  as  quinine 
is  used  for  malaria)  as  giving  the  best  results :  the  disease  is 
mterrupted  rapidly  and  the  interruption  Ls  lasting,  the  disease 
is  not  protracted,  and  does  not  return,  as  in  cases  where  the 
remedy  is  given  timidly  and  m  small  doses,  without  exerting 
any  positive  effect ;  this  is  very  important,  because  the  earlier 
and  the  more  completely  the  disease  is  interrupted,  the  more 
certain  may  the  patient  be  of  avoidmg  the  development  of 
its  dangerous  complications,  cardiac  and  otherwise.  As  soon  as 
the  tinnitus  appears  to  be  sufficiently  pronounced,  as  judged  b}^ 
the  severity  of  the  disease,  I  at  once  discontmue  the  use  of  the 
salycilate.  It  happens  frequently  that  with  the  appearance  of 
a  sufficiently  strong  tinnitus  aurium  the  articular  pains  and  the 
fever  disappear  not  to  return,  so  that  the  remedy  is  not  given 
any  more.  But  if  the  tinnitus  has  markedly  dimmished,  but 
the  pains  and  the  fever  continue,  although  to  a  lesser  extent, 
then  immediately  prescribe  again  sodium  salycilate.  I  begin  m 
adults  with  ten-grain  doses  every  two  hours ;  but  if  the  case  is 
very  severe  and  this  dose  be  well  borne,  I  rapidly  increase  it. 
givB  fifteen  and  later  twenty  grains  every  two  hours,  carefully 
watching,  I  repeat  again,  the  condition  of  the  pulse,  so  that  in 
case  of  necessity  to  administer  stimulants,  as  tinctura  valer. 
gether.  and  liqu.  anodyn.  Hoffm.  aa. 

As  I  said  before,  the  fever  and  the  swelling  of  the  knee-joints 
left  our  patient,  and  the  pains  have  very  much  diminished  in 
mtensity,  but  they  are  still  felt  to  a  slight  degree  wherever  they 
were  formerly,  while  the  tmnitus  aurium,  on  the  cessation  of  the 
administration  of  the  salycilate,  has  continually  diminished  and 
is  now  very  slight.     In  accord,  therefore,  with  the  above-men- 


.„  212  

tioned  rule,  we  will  ag^ain  return  to  this  remedy,  but  without  iii- 
'creasing  its  dose,  because  its  effect  is  satisfactory  as  it  is,  and 
the  case  is  a  light  one. 

Antipyrin  is  also  valuable  in  the  treatment  of  acute  articular 
rheumatism.  There  have  even  been  described  several  cases  of 
the  disease  in  which  the  salycilate  failed,  while  antipyrin  was, 
successful.  I  have  not  met  with  such  cases,  and  guided  by  the 
number  of  my  own  observations  and  those  of  others,  I  still  con- 
sider the  salycilate  of  soda  as  the  most  reliable  drug  in  the  treat- 
ment of  acute  articular  rheumatism  ;  besides,  antipyrin  in  large 
doses  is  even  more  dangerous  for  the  heart  than  is  salycilate  of 
soda. 

The  severity  of  some  cases  of  acute  articular  rheumatism 
with  cardiac  and  other  complications  may,  of  course,  be  deter- 
mined by  the  particularly  severe  effect  of  the  disease-causing 
agent,  —  very  likely  of  a  parasitic  origin,  because  acute  articu- 
lar rheumatism  is  characterized  by  all  the  features  of  an  infec- 
tious and  withal  acute  affection ;  but,  as  I  said  before,  such 
cases  are  chiefly  to  be  observed,  when  the  treatment  of  the 
disease  has  been  long  neglected,  the  disease  not  being  interrupt- 
ed at  the  beginning,  and  the  patient  continues  to  subject  him- 
self to  colds  (as,  for  instance,  by  living  in  cold  rooms,  or  having 
a  cold  water-closet),  and  to  traumatic  influences  (can  not  obtain 
sufficient  rest,  gets  up,  or  generally  moves  around).  In  such 
cases  the  sudden  breaking  up  of  the  disease  does  not  take  place 
and  there  is  no  immediate  return  to  health,  so  that  a  chronic 
affection  of  one  or,  more  frequently,  of  several  articulations  is 
established,  which  goes  under  the  current  name  of  "  chronic 
rheumatism,''^  —  a  name  which  is  not  correct,  is  vague  and  pre- 
vents the  formation  of  a  positive  diagnosis,  and  consequently 
also  treatment,  of  the  various  affections,  which  are  all  without 
any  differentiation  embraced  under  this  term  (I  shall  have  yet 
occasion  to  return  to  this  subject).  The  affection,  usually  of 
one  joint,  which  was  left  over,  passes  often  into  a  condition  of 
severe  inflammation,  which  eventuates  into  pus-formation ;  this 
last  circumstance  points  to  a  superadded  secondary  infection  by 
pyogenic  microorganisms. 

Chronic  affections  of  the  jouits,  remaining  after  acute  articu- 


—  213  — 

lar  rheumatism,  are  often  found  also  in  cases  in  wliicli  it  attacked 
not  a  healthy,  but  a  previously  diseased  organism,  as  for  instance 
a  tuberculous  subject  (thus  in  cases  of  acute  articular  rheuma- 
tism in  youthful  "  scrofulous  "  persons),  or  more  frequently  one 
suffering  with  syphilis  or  gout,  or  even  one  with  only  a  predis- 
position to  gout.  In  view  of  the  coming  lectures  on  "  chronic 
rheumatism  "  and  gout,  I  wish  to  stop  here  to  discuss  the  rela- 
tion of  acute  articular  rheumatism  to  the  latter  disease. 

As  proved  by  facts,  gout  is  the  result  of  an  accumulation  of 
uric  acid  salts  in  the  blood  and  their  deposition  —  principally 
that  of  the  acid  sodium  urate  —  m  various,  or  perhaps  in  all  the 
tissues  and  organs,  most  frequently  in  the  articulations,  in  their 
cartilages  and  other  tissues ;  this  deposition  is  the  cause  of  va- 
rious affections,  according  to  the  variety  of  the  affected  organs. 
Whence  these  uric  acid  salts  accumulate  is  a  debatable  ques- 
tion; but  this  fact  is  certain,  that  such  an  accumulation  is 
promoted  by  excessive  eating  and  by  the  use  of  wine  in  the  ab- 
sence of  active  physical  exercise,  which  means  by  conditions 
which  weaken  in  the  organism  the  processes  of  oxidation.  The 
well-known  clinician  Ebstein  assumes,  not  without  ground,  that 
the  deposition  of  uric  acid  salts  in  the  joints  is  chiefly  favored 
by  an  abundant  formation  of  uric  acid  in  the  organs  adjacent 
to  the  joints,  in  the  bone-marrow  and  the  muscles.  Acute 
articular  rheumatism  is  accompanied  by  a  febrile  condition 
(which  causes  an  increased  formation  of  uric  acid)  and  by  abun- 
dant sweating,  so  that  the  urine  is  greatly  diminished  in  quan- 
tity, becomes  very  red  and  saturated,  and  gives  on  standing  an 
abundant  sediment  of  sodium  urate.  It  is  well  understood,  that 
if  such  a  morbid  process,  which  brings  about  an  increase  in  the 
formation  and  a  decrease  in  the  excretion  of  the  uric  acid  — 
through  a  decrease  in  the  quantity  of  the  urine  —  will  affect 
not  only  a  gouty  person,  but  even  one  with  a  predisposition  to 
gout,  then  this  last  is  bound  to  make  its  appearance  at  once. 
And  as  a  matter  of  fact,  we  often  observe  the  folio wmg : 

A  man,  say,  forty  years  old,  of  good  constitution,  with  supera- 
bundant nutrition  and  good  digestion,  a  good  eater,  who  imbibes 
freely  and  is  physically  inactive,  and  who  has  for  a  long  time 
past  observed  that  his  urine  was  red,  in  short  a  candidate  for 


—  214  — 

gout,  without,  however,  presenting  a  suigle  local  symptom  of  the 
same,  is  suddenly  affected  by  acute  articular  rheumatism,  grows 
feverish,  sweats,  and  passes  some  red  urine  with  an  abundant 
brick-dust  sediment.  Salycilate  of  sodium  is  administered  cor- 
rectly and  the  disease  is  rapidly  interrupted  ;  the  fever  and  the 
pains  disappear.  The  patient  feels  well,  but  in  about  two  to 
three  days  he  returns  complaining  that  the  "  rheumatism  "  re- 
turned in  the  great  toe  of  the  right  foot  and  has  caused  him  excru- 
ciating pam  during  the  whole  night.  The  painful  spot  turns  out 
to  be  swollen  and  red,  but  all  the  other  joints  of  the  body  are  en- 
tirely free  from  pain  and  there  is  no  fever ;  in  short  the  patient  has 
a  typical  attack  of  acute  gout  and  not  the  least  return  of  acute 
rheumatism.  In  other  cases  of  this  last  in  persons  suffering 
with  gout  or  predisposed  to  it,  the  fever  and  the  greater  number 
of  articular  affections  disappear  on  correct  treatment,  but  in  one 
or  more  of  the  affected  articulations  there  will  remain  a  chronic 
disease  by  this  time  of  a  gouty  nature. 

The  further  course  of  the  disease.  —  The  patient  took  six  ten- 
grain  powders  more  of  the  sodium  salycilate,  after  which  the 
tinnitus  increased,  but  the  pains  disappeared  and  there  remained 
only  the  general  weakness.  With  the  aid  of  a  good  appetite 
the  patient  improved  rapidly,  and  December  11th  left  our  clinic. 
During  the  last  days,  before  dismissal,  his  whole  body  was 
sponged  several  times  with  water  and  brandy,  and  this  strength- 
ened him.  On  leaving,  he  was  advised  not  to  take  any  hot 
baths  during  cold  or  damp  weather,  but  instead  to  sponge 
himself  as  above,  and  also  to  drink  less  of  hot  tea. 


TWELFTH  CASE. 


LECTURE  OF  FEBRUARY  19,   J891. 

The  patient,  a  peasant  woman,  58  years  old,  entered  onr  clinic 
January  29tli,  complaining  of  pains  and  swelling  in  the  lower 
and  upper  extremities,  chiefly  in  the  articulations  of  the  wrist  and 
shoulder,  the  knee  and  the  ankle,  and  also  in  the  small  articula- 
tions of  the  hand  and  foot  on  either  side.  She  has  had  the  pains 
there  for  the  last  year  and  a  half  ;  they  are  aggravated  by 
movements  and  make  these  last  extremely  difficult. 

Mode  of  living  and  anamnesis. —  She  has  been  living  for  the 
last  eighteen  months  in  Moscow ;  lived  formerly  in  a  village. 
The  lodgings  are  tolerable,  the  water-closet  cold.  Takes  a  hot 
bath  once  a  month.  Drinks  neither  tea  nor  brandy  now,  nor  did 
she  drink  any  before.  Tlie  food  is  that  of  an  ordinary  work- 
ing woman.  Was  married  and  had  several  children  ;  no  abor- 
tions ;  has  been  a  widow  for  a  long  time.  For  the  last  year  and 
a  half  has  been  unable  to  work  on  account  of  sickness  ;  formerly 
she  did  a  great  deal  of  very  hard  labor  in  orchards.  Has  always 
enjoyed  good  health  up  to  the  appearance  of  the  present  illness. 
In  the  autumn  of  1889,  while  working  durmg  cold  weather  in  the 
orchard,  she  felt  pains  in  the  finger-joints  of  both  hands ;  she 
contmued  at  her  work,  but  the  pains  increased  considerably  and 
to  them  was  superadded  swelling  of  the  painful  spots,  so  that 
it  became  impossible  for  her  to  work.  She  consulted  a  phj^sician, 
who  gave  her  some  ointment,  and  for  internal  use  some  sweet- 
ish powders,  evidently  of  sodium  salycilate.  She  felt  relieved, 
but  the  disease  did  not  disappear  entirely,  and  prevented  her 
from  working  ;  in  such  condition  it  was  protracted  until  the 
beginning  of  the  last  winter  (1891),  when,  with  the  cold 
weather,  the  former  pains  became  worse,  while  fresh  ones  ap- 
peared, accompanied  by  swelling  in  the  remainder  of  the  above- 
enumerated  affected  joints. 


—  216  — 

During  the  three  weeks'  sojourn  of  the  patient  in  the  clinic 
■she  drank  daily  of  Yessentucki  water  No.  17,  —  at  first  one  and 
a  half,  and  later  one  glass  per  day  ;  she  took  several  times  salyci- 
late  of  soda,  at  fu-st  every  other  day  and  later  every  third  day,  in 
quantities  of  twenty  and  later  of  forty  grains  daily,  which  caused 
some  tinnitus  aurium ;  and  since  February  6th,  as  soon  as  the 
affected  joints,  thanks  to  rest,  warmth  and  the  above-mentioned 
treatment^  became  much  less  pamful,  they  were  subjected  to 
massage,  and  later  we  applied  the  electric  static  current :  the 
patient  felt  much  better. 

Status  to-day,  February  19tJi.  —  The  usual  appetite  is  moder- 
ate. The  stomach,  intestines,  liver  and  spleen  are  m  a  normal 
condition.  The  urine  is  reddish,  without  albumen  and  sugar. 
Menopause  established  fifteen  years  ago.  The  organs  of  respir- 
ation are  normal  (the  slight  bronchial  catarrh,  with  which  she 
suffered  on  entering  and  which  caused  some  cough,  passed  away), 
as  well  as  the  organs  of  circulation,  except  that  the  arteries  feel 
somewhat  stiff.  The  patient,  somewhat  spare  for  a  long  time 
past,  has  not  grown  much  thinner  during  the  sickness.  The 
temperature  on  admission  was  slightly  raised,  37.6°  (99.7°^.), 
but  it  soon  became  normal.  The  sleep  is  good.  There  are  no 
pains  in  the  head,  nor  anywhere  else  outside  of  the  above- 
named  articulations.  In  these  last  the  pams  have  considerably 
diminished  and  the  movements  become  much  more  free.  The 
swelling,  which  was  particularly  considerable  (there  is  also 
noticeable  some  fluctuation)  in  the  wrist  and  shoulder-joint,  as 
well  as  in  the  knee-joints  of  both  sides,  has  diminished,  while  the 
slight  redness  observed  on  her  admission,  and  the  higher  tem- 
perature in  the  last-named  articulations,  have  disappeared. 

Diagnosis.  —  The  patient  presents  a  type  of  what  is  usually 
denoted  m  the  text-books  of  special  pathology,  in  literature 
in  general,  as  well  as  in  practice,  as  chronic  articular  rheuma- 
tism ;  or,  if  besides  the  articulations  there  are  also  affected 
other  organs  of  locomotion,  as  the  muscles,  nerves  and  the 
bones  (i.  e.,  all  the  portions  of  the  bones,  and  not  their  articular 
surfaces  only),  then  it  is  simply  designated  as  chronic  rheuma- 
tism. I  had  already  occasion  to  ob3erve  that  I  consider  this 
designation   incorrect,  vague,  and  one  that  prevents    the    for- 


—  217  — 

mation  of  a  positive  diagnosis  (and  consequently  treatment) 
of  the  various  affections,  whicli  are  all,  without  any  differen- 
tiation, embraced  under  this  name.  I  will  take  advantage  of 
the  opportunity  presented  by  this  case,  the  only  one  of  its  kind 
on  hand  at  the  present  time  (although  there  occur  others,  of 
a  more  complicated  nature  and  therefore  more  suitable  for 
my  purpose)  to  elucidate  the  basis  of  my  opinion. 

The  term  rheumatism,  having  long  lost  its  ancient  definition, 
has  even  at  the  present  time  no  concise  meaning :  by  it  is 
meant  on  the  one  hand  an  acute  articular  rheumatism,  —  which 
is  a  sharply  differentiated  disease,  no  less  definite  than  are 
measles,  variola,  typhoid,  typhus,  etc.,  a  disease  which  must 
not  be  confounded  with  any  other,  —  and  on  the  other  hand, 
cases  of  the  nature  of  the  present  one  (of  the  importance  of 
which  I  shall  speak  later),  as  well  as  more  complicated  ones 
that  are  diversified  by  the  affected  organs  as  well  as,  princi- 
pally, by  their  etiology,  and  which  are,  besides,  approaching 
by  their  many  interstitial  (in  the  character  of  their  symptoms) 
manifestations  the  affection  known  as  arthritis  nodosa  sive 
deformans.  Nomenclature  must  of  course  avoid  unnecessary 
destruction,  it  must  not  intrude  on  solidly  based  and  univer- 
sally intelligilDle  defuiition.s,  nor  introduce  unnecessarily,  be- 
fore explaining  fully  the  nature  of  the  subject,  any  new 
terms;  it  should,  however,  strive  for  precision.  If  we  must 
preserve  the  name  rheumatism,  then  it  can  only  be  attamed  on 
the  condition  that  we  give  it  a  definite  designation  :  and  this 
requisite  is  fully  effected  if  we  preserve  this  name  solely 
for  acute  articular  rheumatism,  a  disease,  as  I  said  before,  of 
a  definitely  distinguishable  character.  The  term  rlieumatism, 
as  employed  formerly  in  its  old  definition,  will  certainly  not 
correspond  with  exactness  either  to  what  we  know  already, 
or  to  what  we  will  probably  learn  in  the  future  concerning  the 
nature  of  acute  articular  rheumatism ;  we  find  the  same  facts 
as  regards  the  terms  measles,  small-pox,  scarlatma,  plague,  etc.. 
and  in  their  correspondence  to  the  relative  diseases.  Precise 
definitions  will  be  possible  only  when  the  nature  of  the  enumerat- 
ed diseases  will  be  laiown  with  precision,  but  until  that  time  the 
hnplanted  appellations  have  more  rights  to  existence  and  they 


—  218  — 

must  therefore  remain  :  the  name  rheumatism  for  the  above 
alluded  to  discussed  (m  the  eleventh  case)  acute  aifection  of 
manj  articulations  is  no  less  firmly  implanted  than  are  the 
names  measles,  small-pox,  etc.,  for  the  diseases  designated  by 
them,  and,  I  must  say  again,  it  refers  to  a  sharply  differentiated, 
definite  disease,  just  as  do  these  terms. 

But  if  we  were  to  preserve  the  name  rheumatism  for  acute 
articular  rheumatism,  may  we  then  apply  it,  without  depriving 
it  of  a  defuiite  significance,  to  cases  like  the  present  one  and  to 
others  still  more  complicated,  which  I  mentioned  and  of  which 
I  shall  yet  have  occasion  to  speak  ?  Evidently  not  —  first,  be- 
cause these  cases  differ  one  from  another,  presenting,  as  we 
shall  see  later,  different  affections  origmating  from  various 
causes,  and  secondly,  because  they  are  not  in  the  least  identi- 
cal m  their  nature  with  acute  articular  rheumatism.  Thus  the 
present  case :  at  the  beginning  the  jomts  of  the  fingers  were 
affected  and  became  swollen,  and  they  have  remained  so  until 
now ;  one  yea7'  later  the  other  joints  became  affected,  and  they 
remain  thus  now.  Where  is  here  the  picture  of  acute  articu- 
lar rheumatism  ? 

Do  we  find  here  a  contemporaneous  affection  of  many  articu- 
lations of  a  changeable,  jumping  character,  accompanied  by  a 
febrile  condition,  by  various  complications,  cardiac  and  other- 
wise, which  it  would  be  so  natural  to  expect,  if  the  disease 
were  in  reality  what  passes  under  the  name  of  acute  articular 
rheumatism,  and  one  withal  of  such  long  duration  ?  Fmally,  the 
salycilate  of  soda,  which  acts  m  such  a  specific  manner,  hreciking 
up  so  decidedly  an  attack  of  acute  articular  rheumatism,  acted 
in  this  case  —  to  judge  by  the  history  of  the  disease  and  by  our 
observations  in  the  clinic  —  solelj^  as  a  symptomatic  remedy,  as 
a  slight  pam-stilling  agent,  neither  interrupting  nor  curing  the 
disease. 

There  occur,  it  is  true,  cases  where  an  evident,  typical,  acute 
articular  rheumatism  does  not  terminate  in  a  rapid  breakmg  up 
and  cure  of  the  disease  (usually  on  account  of  the  fact,  that 
the  patient  is  surrounded  by  unfavorable  circumstances,  or  is 
not  treated,  or  is  treated  wrongly  and  not  sufficiently  energetic- 
ally), but  leaves  a  chronic  disease  of  the  affected  joints,  which 


—  219  — 

is  dragged  along  through  months  and  years,  and  is  presented  m 
exactly  the  same  form  as  the  present  case,  namely,  without  any 
characteristic  peculiarities  of  acute  articular  rheumatism,  un- 
yieldmg  to  treatment  by  the  salycilate,  which  fails  to  cure  it. 
To  denommate  such  cases  by  the  term  of  chronic  articulai- 
rheumatism,  i.  e.,  to  consider  them  as  cases  of  acute  articu- 
lar rheumatism —  a  disease  havhig  all  the  peculiarities  of  an  acute 
infectious  process  —  which  passed  into  a  chronic  condition, 
would  be  the  same,  as  if  we  were  to  consider  chronic  bronchial 
catarrh,  which  is  sometimes  left  after  measles,  as  chronic  measles, 
or  the  diarrhoea  left  after  an  attack  of  typhoid  fever,  as  chronic 
typhoid.  It  is  apparent,  that  in  all  these  cases  it  was  not  the 
acute  infectious  disease  which  passed  mto  a  chronic  condition, 
but  there  were  left  local  affections,  which  are  caused  by  and, 
under  favorable  conditions,  disappear  with  the  disease,  and  under 
unfavorable  circumstances  become  chronic. 

In  the  chronic  affection  of  the  joints,  which  remams  after  an 
attack  of  acute  articular  rheumatism,  there  take  place  at  times 
apparent  recurrences  of  this  last :  thus  there  appears  a  febrile 
condition,  the  affection  of  the  jomts  becomes  aggravated  and 
takes  on  a  migratmg  character,  and  the  salycilate  of  soda  exerts 
anew  its  beneficial  effect.  But  such  recurrences  of  acute  artic 
ular  rheumatism,  which  are  generally  so  very  peculiar  to  this 
disease  and  which  occur  frequentl}-  also  in  cases  where  its  attacks 
leave  no  trace  of  any  chronic  affection  of  the  joints,  cannot  go 
to  prove  the  fact,  that  the  chronic  articular  affection,  which  in 
the  intervals  between  the  attacks  extended  over  months  and 
years,  is  identical  with  the  acute  infectious  disease,  which 
passes  under  the  name  of  acute  articular  rheumatism. 

What  then  do  these  cases  of  chronic  joint  affection,  of  polyar- 
thritis chronica,  as  our  present  one  and  others  mentioned  by  me, 
present  ?  Here  it  becomes  particularly  necessary  to  employ 
careful  clinical  analysis :  I  usually  make  m  such  cases  a  dou])le 
investigation  and  a  double  diagnosis  —  the  anatomical,  defining 
the  affected  organs  and  tissues,  and  the  etiological,  referring  to 
the  causation  ;  I  resort  to  this  j^rmcipally  because  the  therapy 
presents  differences  not  only  m  accord  with  the  causes,  but  als(j 
with  the  affected  organs,  as  joints,  bones,  muscles  and  nerves. 


—  220  — 

The  anatomical  investigation  gives  the  following :  the  most 
frequently  and  preeminentl}'  affected  parts  are  the  joints ;  in 
these  we  must  determine  the  condition  of  the  articulating  ends 
of  the  bones  and  of  their  cartilages,  the  condition  of  the  articu- 
lating capsule  and  of  the  soft  parts  outside  of  it.  Less  frequent- 
ly are  observed  affections  —  usually  with  pain  and  swellmg  — 
of  other  parts,  besides  the  jomts  ;  it  then  becomes  necessary  to 
determine  just  what  part  is  affected :  the  skin,  as  evidenced  by  a 
hyperaesthetic  condition,  by  dermatitis,  etc.,  or  the  bones,  most 
frequently  in  the  form  of  a  periostitis,  accompanied  by  pain, 
which  becomes  aggravated  on  pressure,  —  and  sometimes  by 
swelling ;  or  the  cartilages,  as  seen,  for  mstance,  in  a  perichon- 
dritis of  the  costal,  laryngeal  and  aural  cartilages,  —  most  fre- 
quently m  gout ;  this  condition  also  is  accompanied  by  pain, 
which  becomes  worse  on  pressure ;  or  it  may  be  the  muscles,  as 
proved  by  the  existence  of  a  myositis :  a  high  temperature,  ten- 
sion and  sensitiveness  on  pressure  and  motion,  and,  later  on, 
emaciation  of  the  affected  muscles,  m  which  cirrhotic  indura- 
tions may  form  ;  or  the  nerves,  in  the  form  of  a  neuritis :  pains, 
tenderness  on  pressure  and  various  functional  disturbances. 

The  investigation  of  the  causes  brings  to  surface  most  fre- 
quently the  following :  acute  articular  rheumatism,  and  also, 
although  much  less  frequently,  other  acute  mfectious  diseases, 
gonorrhoea  (I  cannot  help  observing,  that  the  name  polyar- 
thritis gonorrhoica  is  much  more  preferable  to  the  meaningless, 
vague  term  "  gonorrhoeal  rheumatism"),  syphilis,  tuberculosis, 
gout,  a  cold,  traumatic  influences,  (of  these  last  not  so  much 
those  of  an  acute  nature,  —  contusions,  wounds,  etc.,  —  as  the  less 
severe,  but  constantly  acting  ones,  as  intense,  fatiguing  phj^sical 
activity)  and  abuse  of  alcoholic  drinks ;  for  although  alcohol 
does  not  cause  directly  any  joint  affections,  it  undoubtedl}^ 
creates  a  predisposition  to  them. 

Chronic  affections  of  the  joints,  as  I  said  once,  are  usually 
not  of  a  simple,  but  of  a  complicated  origin,  depending  on  the 
effect  not  of  one,  but  of  several,  even  of  many  causative  agen- 
cies, as,  for  instance,  of  the  conjoined  action  of  a  former  acute 
articular  rheumatism  and  at  the  same  time  of  gout,  syphilis,  of 
a  cold  and  of  traumatic  influences. 


—  221  — 

What  general  name  then  is  more  suitable  for  those  chronic 
affections  of  which  we  are  speaking  at  present  ?  If  we  desire 
to  preserve  the  briefness  so  essential  in  a  term,  then  it  is  best 
to  call  them  i^oly arthritis  chronica^  because  the  affections  of  the 
joints  are  usually  predominant,  and  such  a  name  neither  deter- 
mines beforehand  the  concise  diagnosis  —  and  therefore  the 
treatment  —  of  the  given  case,  nor  does  it  render  it  obscure,  as 
is  the  case  with  the  term  chronic  "  rheumatism." 

We  will  turn  now  to  the  analysis  of  the  present  case.  Per- 
sons of  our  patient's  age,  —  fifty-eight  years,  —  living  in  the 
midst  of  miserable  conditions,  full  of  privations,  suffer  often 
from  a  particular  form  of  gout,  the  so-called  atonic  gout,  as 
distinguished  from  the  other,  the  ordinary  form,  to  which  we 
alluded  m  our  previous  case.  In  our  patient  there  are  no 
characteristic  manifestations  of  gout,  as,  for  instance,  affections 
of  the  joints  of  the  great  toes,  neither  the  generally  preeminent 
affection  of  the  small  joints  (both  the  small  and  the  larger  ones 
are  affected),  nor  any  apparent  gouty  deposits  around  the  artic- 
ular ends  of  the  bones ;  but  she  presents  indications  of  a  pre- 
disposition to  gout  —  the  constantly  red  urine  and,  as  observa- 
tion in  the  clinic  made  it  evident,  the  favorable  action  on  the 
patient  of  an  alkaline  (Yessentucki)  mineral  water.  This  pre- 
disposition to  gout  explams  the  fact,  why  the  certain  mfluences, 
traumatism  and  cold,  to  which  the  patient  subjected  herself 
with  impunity  during  the  whole  of  her  laborious  life,  have  at 
last,  in  her  old  age,  caused  the  appearance  of  an  articular 
disease.  As  regards  the  so  much  apparent  influence  of  cold 
(she  was  taken  sick  twice  during  the  beginning  of  cold 
weather),  it  is  worth  wliile  noting,  that  precisely  those  joints 
became  affected,  which  were  either  uncovered  —  as  those  of 
the  fingers,  and  the  wrist,  or  but  insufficiently  protected  —  as 
those  of  the  knee  and  of  the  ankle  (as  the  patient  wears  neither 
drawers  nor  a  petticoat,  while  the  soles  were  protected).  As 
mentioned  above,  in  the  diseased  joints  the  affection  is  found 
in  the  soft  parts,  located  outside  of  the  articular  capsule,  as 
evidenced  by  the  swelling  and  by  the  higher  temperature  and 
slight  redness  on  admission,  and  in  the  capsule  itself  (fluctua- 
tion detected)  ;  there  are  no  signs  of  any  affection  of  the  bones. 


Prognosis.  —  Judging-  by  the  favorable  course  of  tlie  treat- 
■ment,  we  may  hope  for  a  satisfactory  issue  of  the  disease  ;  we 
may  expect  a  return  to  a  considerable  extent  of  freedom  of 
motion,  in  case,  certainly,  the  patient  succeeds  in  avoiding-  m 
the  future  any  deleterious  influences,  which  are  liable  to  cause 
a  recurrence  of  the  disease. 

Treatment.  —  Wh}^  we  prescribed  for  our  patient,  with  her 
predisposition  to  gout,  an  alkaline  water,  and,  m  view  of  her 
ao-e  and  poor  nutrition,  a  small  quantity  of  the  same,  you 
certainly  understand  well.  I  will  only  add  that  when  atonic 
gout  be  fomid  in  patients,  who  have  been  ailing  for  a  long  time 
before  with  the  usual  form  of  gout,  who  drank  a  great  deal 
of  mineral  alkaline  waters,  and  whose  nutrition  suffered  con- 
siderably, then  we  must  admmister  to  them  either  the  lightest 
alkaline  watere  (Ems),  or  the  earthy  waters  (Contrexeville). 
To  be  sure,  our  patient's  nutrition  is  not  of  the  best,  but  still 
we  cannot  call  it  very  poor,  and  as  she  never  drank  any  min- 
eral waters,  w^e  therefore  prescribed  for  her  a  very  active 
alkaline  water  (Yessentucki,  No.  17),  but,  as  I  said  before, 
in  a  small  quantity,  and  the  course  of  the  treatment  justifies 
completely  this  conduct  of  ours.  The  salycilate  of  soda,  as 
a  pain-stilling  agent,  has  relieved  the  patient  sufficiently, 
Massao'c  and  the  constant  electric  current  seem  to  exert  a  favor- 
able  influence  by  diminishing  the  articular  swelling  and  by 
making  motion  easier.  "We  will  therefore  continue  the  Yes- 
sentucki water,  a  half-glass  twice  a  day,  the  application  of 
massage  and  of  electricity ;  but  there  is  no  more  need  for  the 
salycilate.   nor  for    any   other   pam-stilling    drugs    in    general. 

We  limit  ourselves  to  the  above-named  means,  because  they 
seem  to  be  sufficient.  An  excellent  remedial  agent  for  chronic 
joint  affections  we  have  in  the  salt  baths,  warm  or  even,  m  the 
absence  of  contra-mdications,  hot :  we  do  not  resort  to  them 
in  the  present  case,  because  we  can  seemmgly  get  along 
without  them,  but  prmcipally  because  they  are  contra-indicated 
by  the  season,  it  being  wmter  time :  the  patient,  after  leaving 
our  clinic,  would  subject  herself  to  a  greater  risk  in  catching 
cold.     A  good  remedy  for  chronic  articular   affections   is    car- 


^  'in  — 

bolic  acid  (in  the  form  of  fomentatious  of  a  two  to  four  per 
cent  solution  and  hypodermic  injections) ;  there  is  no  need 
for  it  in  the  present  case,  and,  besides,  injections  of  carbolic  acid 
cause  severe  pains.  The  iodine,  as  well  as  the  mercurial 
preparations,  are  undoubtedly  useful  m  articular  affections 
when  complicated  by  syphilis. 

In  prescribmg  local  treatment  attention  must  be  paid  as  to 
what  organs  or  tissues  are  affected.  For  muscles  the  best  thing 
is  massage.  For  the  articulations  —  Spanish  fly,  massage,  elec- 
tricity and  carlx)lic  acid.  For  affections  of  the  periosteum 
only  general  treatment,  usually  anti-syphilitic  or  anti-gouty,  or 
both  together,  as,  for  instance,  iodine  preparations  m  alkaline 
mineral  waters  ;  massage  and  electricity  increase  the  pains  and 
aggravate  the  disease.  For  the  neurites  —  rest,  Spanish  fly, 
irritating  and  paiu-stilling  salves,  and,  at  the  end  of  the  acute 
stage,  a  careful  massage,  not  of  the  nerve  itself,  but  with  a 
derivative  aim  m  view,  of  the  neighboring  parts,  chiefly  of  the 
muscular  masses  ;  the  action  of  electricity  is  not  certain. 
Finally,  I  repeat  again,  salt  baths,  warm  or  hot,  are  useful  in 
all  the  affections. 


FROM  THE  LECTURE  OF  MARCH  I,  1 89 1. 

The  patient  leaves  the  clinic  to-day.  All  the  functions  are 
normal,  the  nutrition  as  well  as  the  strength  has  improved. 
The  swellmg  remams,  althoughjmuch  less  than  it  was  before, 
only  in  the  wrist-joints,  while  from  the  others  it  has  almost 
passed  away.  There  is  an  entire  absence  of  any  pains  on 
pressure,  or  on  passive  and  short  active  movements.  A  pro- 
longed walk  gives  rise  to  a  feeling  of  fatigue,  and  later  also 
of  pain  in  the  knees,  which,  however,  soon  pass  away  after 
rest. 

Patient  was  advised  to  avoid  certain  harmful  influences  and 
to  continue  massao-e. 


THIRTEENTH   CASE. 


LECTURE  OF  MARCH  3,  1892. 

The  patient,  a  widow  of  an  official,  is  forty-seven  years  old, 
and  entered  our  clinic  February  27tli  complaining  of  severe 
pains  in  the  loins  and  in  the  thighs  down  to  the  knees ;  the 
pains  are  very  much  aggravated  on  motion,  so  that  this  last  is 
almost  impossible ;  she  also  complains  of  pains  in  the  chest  and 
in  the  left  half  of  the  abdomen. 

Mode  of  living  and  anamnesis.  —  The  patient  is  an  inhabitant 
of  one  of  the  governments  around  Moscow,  lives  in  a  healthy 
locality  and  occupies  a  good  house,  but  the  water-closet  is  cold. 
Has  not  bathed  in  the  river  for  the  last  five  years,  takes  a  hot 
bath  twice  a  month,  perspires  very  freely.  Drinks  no  coffee, 
wine  or  whiskey,  only  some  four  glasses  of  hot  tea  per  day ; 
generally  drinks  but  little:  besides  the  tea  only  water,  not 
more  than  one  glass  during  the  whole  day.  She  breakfasts  and 
dines  at  a  good  table,  eats  many  sweets.  Has  been  a  widow 
for  the  last  five  years  ;  was  never  pregnant.  Goes  out  but  little 
mto  fresh  air,  has  but  little  exercise.  Her  occupations  are 
those  of  a  small  housekeeper. 

Patient  comes  from  a  healthy  family  and  is  herself  of  a  strong 
constitution ;  in  her  seventeenth  year  she  passed  through  an 
attack  of  typhoid,  in  her  twenty-seventh  had  malaria.  Has  en- 
joyed good  health  since,  up  to  the  climacteric  period,  which 
began  five  years  ago :  the  first  three  years  the  menstruation  was 
irregular,  but  two  years  ago  it  ceased  entirely.  With  the 
advance  of  the  climacteric  period  there  began  to  appear  attacks 
of  heat  in  the  head  and  pronounced  perspiration  all  over  the 
body ;  they  were  of  frequent  occurrence  during  the  fii'st  year, 
several  times  daily ;  since  that  time  the  quantity  of  the  urine 
dimmished,  the  urine  became  red  and  left  frequently  a  reddish 
224 


—  225  — 

precipitate.  Four  years  ago  she  had  for  the  first  time  a  very 
severe  attack  of  renal  colic  on  the  left  side,  as  evidenced  by 
pains  in  the  left  loin  transmitted  to  the  left  groin,  which  lasted, 
with  intervals,  for  four  days.  A  year  later  she  had  another 
attack  of  lesser  severity,  lasting  two  days.  After  that  the 
attacks  of  renal  colic  took  place  frequently,  always  on  the  left 
side,  but  they  were  not  of  severe  intensity.  Since  October  1891 
there  appeared  a  constant  severe  pam  in  the  left  loin  and  on  the 
corresponding  side  of  the  abdomen,  and  smce  then  began  all 
those  pains  with  which  the  patient  entered  the  clinic,  and 
which  kept  continually  on  the  increase.  The  treatment  was  as 
follows :  at  the  beginnmg  sodium  salycilate  until  the  production 
of  tmnitus  aurium  during  one  month,  but  without  any  success  ; 
then,  for  one  month,  potassium  iodide  (dose  unknown)  in  solu- 
tion, three  spoonfuls  per  day ;  no  results  whatever.  Later,  cool 
spongings  with  a  wet  towel  for  one  month,  also  without  any 
success ;  finally,  for  two  weeks  before  she  entered  the  clinic, 
the  patient  drank  Vichy-Celestins  (she  never  used  any 
mineral  water  before),  about  one  glass  and  a  half  per  day,  and 
felt  slightly  relieved.  While  in  the  clinic  the  patient  continues 
drinking  the  same  water  warmed  to  the  temperature  of  freshly 
drawn  milk,  three  half-glasses  during  the  day,  each  time  one 
hour  before  a  meal. 

Status.  —  The  appetite  is  impaired.  While  observing  a  strict 
diet  and  using  Vichy  in  the  clinic,  she  has  no  dyspeptic  symp- 
toms, but  formerly  she  felt  heaviness  in  the  stomach  and  pyro- 
sis almost  constantly.  The  patient  is  usually  constipated  and 
takes  castor  oil  twice  a  month ;  in  the  clinic  the  rectum  is 
sufficiently  emptied  with  the  aid  of  watery  clysters.  The  liver 
and  the  spleen  are  in  normal  condition.  The  pahis  on  the  left 
side  of  the  abdomen  are  due  to  the  considerable  tenderness  of 
the  kidney  and  the  ureter ;  on  the  right  side  the  kidney  and  the 
ureter  are  also  tender  on  pressure,  but  much  less  so.  For  a  few 
days  before  her  admission  to  the  clinic,  the  patient  discontinued 
drinking  Vichy  and  the  quantity  of  urine  on  her  admission  was 
small,  —  500  to  700  c.c.  in  twenty-four  hours,  the  urine  very  red,  of 
a  strongly  acid  reaction,  with  a  considerable  deposit,  principally 
of  sodium  urate ;  at  present,  when  the  patient  resumed  drinking 


—  226  — 

Vich}^,  and,  as  we  advised,  not  verj  hot  tea  (she  thus  perspires 
less)  and  a  greater  quantity  of  ordinary  water,  the  amount  of 
urine  increased  from  1000  to  1200  c.c.  in  the  twenty-four  hours, 
the  urme  is  not  so  red,  and  the  sediment  is  much  smaller. 
Urine  contains  neither  albumen,  nor  sugar.  The  organs  of  res- 
piration are  healthy.  The  dimensions  of  the  heart  are  normal, 
its  tones  clear,  but  the  pulse  is  somewhat  weak,  which  points 
to  an  insufficient  activity,  and  probably  to  the  already  affected 
nutrition  of  the  cardiac  muscle,  a  condition  so  very  natural  in  a 
sick  woman  who  takes  so  little  exercise.  The  patient  was  former- 
ly stout,  but  grew  thin  during  the  disease,  and  yet  she  cannot  be 
said  to  be  emaciated.  There  is  no  fever.  The  pains  prevent 
sleep  to  some  extent,  but  yet  it  is  quite  sound  and  sufficiently 
prolonged.  The  pains  in  the  chest  of  which  the  patient  com- 
plains, are  proved  by  investigation  to  depend  on  the  sensitive- 
ness of  the  sternum,  ribs  and  scapulae  ;  but  most  sensitive  are  the 
pelvic  bones  (especially  the  sacrum)  and  both  femurs ;  the 
movements  of  the  acetabular  articulations  are  extremely  pain- 
ful, which  condition  causes  great  difficulty  in  turning  over  in 
bed,  and  makes  getting  up  and  walkhig  about  almost  impossible  : 
the  patient,  as  you  saw,  was  carried  mto  the  auditorium  on  a 
chair. 

Diagnosis.  —  It  is  evident,  that  we  have  here  to  deal  with 
a  typical  case  of  gout,  arthritis  urica.  The  patient,  of  strong 
constitution,  with  a  hitherto  good  digestion,  lived  always  in 
affiuence,  ate  more  than  was  necessary,  had  but  little  exercise, 
no  children,  grew  stout,  and  with  the  approach  of  the  climac- 
teric period  with  its  peculiar  vasomotor  disturbances  (frequent 
"  bathing "  of  the  whole  body  in  sweat,  which  increased  the 
patient's  usual  tendency  to  perspiration),  she  began  to  excrete 
a  diminished  quantity  of  red  urine  with  an  abundant  uric-acid 
deposit  and  began  to  suffer  from  renal  colic,  a  disease  to  which 
gouty  persons  are  so  liable  to  be  subject,  as  it  is  connected 
with  the  very  nature  of  gout :  then  there  appeared  the  above- 
mentioned  pains  in  the  bones,  gouty  periostites. 

Is  not  there  also  syphilis  m  the  case,  as  the  pains  prevent 
quiet  sleepmg  at  times  ?  It  is  true  that  the  pains  interfere  with 
the  sleep,  but    only    when    the    patient    while    asleep    makes 


—  227  — 

a  movement  causing  pain ;  this  last  causes  the  patient  to 
start  up,  but  after  a  rest  the  pain  passes  away  and  the  patient 
again  goes  fast  asleep.  But  the  nocturnal  exacerbations  of 
syphilitic  pains  are  of  a  different  nature,  they  last  longer, 
for  many  an  hour,  and  are  not  relieved  by  quiet  posture ;  on 
the  contrary,  such  patients  at  times  get  up  and  prefer  to  walk 
about  during  the  nocturnal  attacks  of  these  pains.  I  will  not 
stop  here  to  discuss  the  point,  that  the  bones  which  are  most 
frequently  affected  in  syphilis,  as  for  instance,  the  tibiee,  the 
bones  of  the  forearm,  of  the  skull,  are  not  affected  here ;  nor 
are  there  any,  specially  characteristic  of  gout,  affections  of  the 
small  joints,  and  particularly  of  the  great  toes.  But  whereas 
the  anamnesis  and  the  present  condition  point  with  such 
positiveness  to  gout,  they  fail  to  give  any  indications  of  syphilis. 
Finally,  one  month's  treatment  with  potassium  iodide  brought 
absolutely  no  improvement,  while  a  two  weeks'  use  of  Vichy 
water  has  produced  an  inconsiderable  but  nevertheless  un- 
doubted relief.  As  to  what  concerns  the  fact,  that  in  our  patient 
it  is  the  pelvic  bones  and  the  femur  which  are  preeminently 
affected  by  the  gout,  it  is  quiet  possible,  that  this  was  aided  by 
a  cold  while  sitting  down  in  the  water-closet  m  the  beginning 
of  the  cold  weather,  last  October,  when  the  buttocks  and  the 
thighs  were  exposed  to  chilling  blasts. 

Prognosis.  —  Experience  proves  that  patients  like  the  one 
before  us  become  usually  free  from  the  severe  symptoms  of 
gout  and  its  recurrences,  after  an  ordinarily  repeated  use 
of  mineral  waters  (at  the  beginning  alkaline,  later  alkaline  and 
earthy)  and  a  strict  observance  of  hygienic  regulations. 

Treatment.  —  As  a  cause  of  failure  of  the  former  treatment 
we  must  apparently  consider  the  vagueness  in  the  diagnosis. 
The  physician  saw  what  he  considered  as  "  chi'onic  rheuma- 
tism," and  during  a  whole  month  he  was  admmistermg  sodium 
salycilate  till  the  production  of  tinnitus  aurium,  but  without 
any  success ;  salycilate  of  soda  is  perfectly  inert  in  cases 
of  gouty  affections  proper,  and  especially  in  gouty  periostites  ; 
it  acts  solely  as  a  pain-stillmg  agent,  and  then  in  connection 
with  alkaline  mineral  waters,  only  in  gouty  articular  affections 
complicated  by  acute  or  subacute  articular  rheumatism  or  by 


—  228  — 

the  affection  of  the  joints  consequent  upon  this,  as  well  as 
.  by  a  catarrhal  condition  of  these  last.  The  failure  of  the 
treatment  and  a  suspicion  of  syphilis  led  to  the  employment 
of  potassium  iodide,  although  it  would  have  been  more  judi- 
cious to  administer  at  first  an  alkaline  mineral  water,  because, 
whereas  the  presence  of  syphilis  was  suspected,  the  presence  of 
gout  was  beyond  doubt.  An  indication  for  the  employment 
of  cool  sponging  could  be  found  either  in  the  nervousness  of 
the  patient,  who  was  harassed  by  pains,  or  again,  in  the  vague 
idea  about  "  chronic  rheumatism ; "  but  the  nervousness  could 
certainly  not  be  removed  without  setting  aside  its  causes, 
namely,  the  contmuous  pains ;  as  for  pains  in  general,  and 
particularly  for  those  of  renal  origm,  warm  baths  are  more 
suitable  than  the  cool  spongings  (whether  or  not  warm  baths 
are  suitable  m  the  present  case,  we  shall  see  later  on). 

The  patient  was  given  Vichy,  as  experience  proves  that 
the  strong  alkalme  waters,  as  Vichy  and  Yessentucki,  are  the 
best  remedial,  agents  m  such  a  typical  gout,  as  found  in  our 
patient  (later  on,  in  atonic  gout.  Ems  or  an  earth}'  water 
like  Contrexeville  is  more  suitable).  We  administer  Vichy 
in  a  moderate  quantity,  although  it  would  be  desirable  to  give 
it  in  a  larger,  because  the  patient  is  not  only  unable,  in  view 
of  the  winter,  to  go  out  of  doors,  but  she  can  not  as  yet  even 
walk  about  the  room :  such  being  the  case,  a  considerable 
quantity  of  an  easily  absorbable  water,  which  has  no  tendency 
to  loosen  the  bowels,  would  increase  the  vaso-motor  distur- 
bances in  our  patient,  the  mfluxes  of  blood  to  the  head,  and 
the  perspiration,  which  last  would  diminish  the  secretion  of  the 
urine.  As  we  cannot  administer  any  considerable  quantity 
of  the  mmeral  water,  we  shall  be  compelled  to  give  it  for  a 
longer  period  of  time. 

What  else  shall  we  prescribe  for  our  patient  to  hasten  her 
relief  and  improvement  ?  As  was  said  once,  and  as  proved  by 
experience,  we  have  nothing  to  expect  from  the  salycilate  of 
soda,  of  which  the  patient  took  so  much.  The  same  may  be 
said  of  antipyrin  and  other  similar  medical  agencies,  the  action 
of  which  is  so  similar  to  that  of  the  salycilate.  Besides,  these 
remedies  are  not  only  useless  in  the  given  case,  but  even  harm- 


—  229  — 

ful,  as  they  increase  the  tendency  to  sweating,  which  prevents 
the  excretion  of  a  sufficient  quantity  of  urine,  and  weakens  still 
more  the  cardiac  activity,  weak  as  it  is  at  present. 

To  give  for  the  present  case  the  preparations  of  opium  for 
the  relief  of  the  pains  would  be  very  erroneous,  as  they  would 
aggravate  the  above-mentioned  vasomotor  disturbances,  which 
so  distress  the  patient  (as  the  influxes  of  blood  to  the  head), 
and  prevent  sufficient  urinary  secretion  (as  the  perspiration). 
It  were  most  desirable  to  diminish  the  pains  in  a  radical  manner 
by  removing  their  causes,  which  consist,  namely,  in  those  pecu- 
liar gouty  deposits  of  sodium  urate  in  the  painful  parts. 

Lithium,  used  for  this  purpose,  is  imdoubtedly  effective, 
but  not  to  a  particular  extent.  We  will  prescribe  for  our 
patient  piperazine  recommended  recently,  which  seems  to  pro- 
mote solution  and  removal  of  uric  acid  deposits ;  there  exist  ui- 
vestigations  w^hich  speak  much  in  favor  of  piperazine.  We 
will  prescribe  it  in  solution,  (]J.  piperazini  3],  aquee  destil.  fvj) 
in  tablespoonful  doses  three  times  a  day,  consequent!}^  fifteen 
grains  a  day,  immediately  before  taking  her  Vichy  water. 

Of  external  means,  in  the  present  case  with  gouty  periostites, 
electricity  is  useless,  while  massage  is  even  harmful,  as  it  may 
aggravate  the  pains.  Warm  baths  are  contraindicated  by  the 
extreme  sensitiveness  on  movmg  about :  the  acts  of  undressmg, 
getting  mto  the  bath,  emerging  therefrom  and  di-essing  anew, 
would  aggravate  the  pains  to  a  greater  extent,  than  they 
would  be  relieved  by  a  warm  bath.  ^loreover,  for  this  case  we 
should  have  to  employ,  m  view  of  the  great  tenderness  of  the 
kidney  and  of  the  ureter  in  the  left  side,  very  warm  baths, 
which  again  would  increase  the  tendency  to  perspiration  so 
harmful  for  our  patient. 


FROM  THE  LECTURE  OF  MARCH  27,   1892. 

The  patient  continues  to  drink  Yichy,  and  from  March  4th  to 
25th  she  had  been  taking  piperazme.  Her  condition  has  im- 
proved considerabl3%  all  the  pains  in  the  bones  as  well  as  in  the 
kidneys  have  very  much  diminished:  the  patient  walked  with 


—   230  — 

ease  into  the  auditorium.  All  her  functions  are  regular,  the 
urine  is  not  red,  gives  no  sediments  and  is  of  a  weak  acid  re- 
action, the  sleep  is  sound,  there  are  no  nocturnal  pains,  as  the 
motions  are  painless. 

As  to  what  concerns  the  action  of  piperazine,  it  would  seem, 
that  after  it  was  administered  the  relief  of  the  pains  appeared 
sooner,  in  fact  much  sooner ;  however,  we  cannot  be  sure  about 
this,  as  the  patient  drank  at  the  same  time  Vichy  water,  the 
use  of  which  we  could  not,  to  make  the  experiment  clear,  set 
aside,  on  account  of  the  patient's  aggravated  condition.  The 
stomach  bore  the  piperazine  well  in  the  above-named  dose,  and 
the  drug  has  in  general  failed  to  cause  any  unpleasant  signs.* 

As  we  were  unable,  as  said  before,  to  give  the  mineral  water 
in  large  quantities,  we  must  continue  its  use  for  as  long  a  time 
as  possible. 

The  further  history  of  the  disease.  —  April  7th  patient  left  the 
clinic  almost  without  suffering  any  pains.  Until  the  time  that 
she  left  the  clinic  she  drank  Vichy  in  the  former  quantity :  the 
urine  became  pale  and  had  at  times  a  neutral  reaction.  Patient 
was  advised  to  discontinue  drinking  the  mineral  water,  but 
during  the  summer,  in  case  of  a  recurrence  of  the  pains,  even  if 
they  be  not  severe,  to  renew  drinking  Vichy,  in  the  same  quan- 
tity, but  for  a  shorter  period,  say  three  or  four  weeks,  and  also, 
if  possible,  to  take  lukewarm  baths  of  27°  R.  (92.7°  F.~) 
with  salt  and  soda,  of  the  first  some  six,  of  the  last  some  three 
pounds  per  bath  ;  experience  has  shown  the  utility  of  such  baths 
for  gouty  persons ;  she  must  certainlj-  observe  most  carefully 
her  individual  hygiene,  as  explained  to  her.  She  was  advised 
to  take  more  exercise,  but  with  due  rest,  never  fatiguing  her- 
self, and  especially  avoid  fatiguing  the  formerly  diseased  parts. 

*  Further  observations  proved  tliat  piperazine  cannot  be  relied  upon  ; 
that  its  action,  if  it  has  such,  is  insignificant  and  uncertain,  and  that  it 
belongs  to  the  class  of  drugs,  which  have  recently  been  pushed  to  the 
front  by  speculation  and  advertised  by  pseudo-scientific  methods. 


FOURTEENTH  CASE. 


LECTURE  OF  OCTOBER   H,  I89I. 

The  patient,  the  wife  of  a  tradesman,  is  thirty-two  years  old ; 
she  entered  our  clinic  October  2d,  complaining  of  pains  all  over 
the  body,  and  particularly  in  the  abdomen,  in  the  right  side,  in 
the  chest,  arms  and  legs  ;  of  dyspnoea,  palpitation,  oedema  of 
the  legs,  poor  sleep  and  general  weakness. 

Mode  of  living  and  anam^iesis.  —  Patient  lives  in  one  of 
the  governments  around  Moscow,  m  a  good  locality  and  in  a 
good  house.  Never  bathed  in  the  river  much,  and  for  the 
last  five  years  has  not  bathed  at  all,  as  it  caused  attacks  of 
severe  dyspnoea.  Visits  once  a  week  the  public  bath-house ; 
is  not  subject  to  sweating.  She  drinks  two  to  three  cups 
of  tea  and  a  glass  of  coffee;  has  never  used  any  alcoholic 
drinks.  Her  order  of  meals  —  breakfast,  dinner  and  supper; 
patient  was  always  very  intemperate  in  her  eating,  and  is  very 
fond  of  fatt}^  starchy  and  particularly  of  sv/eet  articles  of  food. 
She  was  pregnant  twice,  last  confinement  nine  years  ago.  She 
has  some  trifling  household  occupation  ;  during  the  cold  season 
of  the  year  patient  almost  never  goes  out-of-doors ;  in  summer 
she  is  out-of-doors  some,  but  on  account  of  ill-health  hardly 
ever  walks  at  all ;  which,  however,  she  did  not  do  even  while 
well,  because  she  never  liked  walking. 

Patient  comes  from  a  healthy  family  and  is  herself  of  very 
robust  constitution.  Has  always  lived  in  the  above-described 
manner,  always  ate  much  and  exercised  little  ;  with  the  cessation 
of  pregnancies  she  became  very  stout,  and  five  years  ago 
began  to  suffer  with  biliary  colic,  in  the  form  of  character- 
istic attacks  of  severe  pains  in  the  right  side  accompanied  by 
vomiting  and  jaundice.  October  1886  she  entered  our  clinic 
the  first  time,  and  we  found  that  besides  general  obesity  and 

231 


—  232  — 

biliary  calculi  there  was  also  a  clearly  pronounced  gout,  ex- 
pressed in  renal  colic,  the  urine  giving  an  abundant  sediment 
of  sodium  urate,  and  in  gouty  periostites  of  tUe  various  bones 
and  especially  of  the  ribs  (there  was  neither  then,  nor  is  there 
now  any  sign  of  syphilis).  The  patient  observed  the  diet, 
drank  Vichy,  took  several  warm  baths,  and  in  the  course  of  a 
month  left  the  clinic  greatly  improved ;  but  notwithstand- 
ing the  fact,  that  we  pointed  out  to  her  clearly  what  her  mode 
of  living  would  bring  her  to,  she  did  not  in  the  least  alter 
it,  and  in  January  1887  was  again  compelled  to  reenter  our 
clmic,  in  which  she  remained  for  a  month,  was  treated  m  a  sim- 
ilar manner  and  left  the  clinic  again  improved.  But  being  of  a 
weak  will-power,  she  returned  to  her  former  mode  of  livmg 
again,  and  in  October  1887  she  applied  to  the  clinic  for  the 
third  time,  with  all  her  former  troubles,  which  became  worse 
this  time,  and  were  especially  accompanied  by  a  severe  renal 
colic.  The  treatment  consisted  in  giving  her  calomel  several 
times,  warm  baths,  and  later  on  Karlsbad  and  Vichy.  Patient 
agam  improved  considerably,  and  notwithstanding  her  former 
irregular  mode  of  living,  but  little  changed  for  the  better, 
she  enjoyed  comparatively  good  health  durmg  almost  a  whole 
year,  and  only  in  October  1887  she  was  again  compelled  for  the 
fourth  time  to  apply  for  treatment ;  she  was  given  calomel  once, 
and  later  drank,  during  a  period  of  six  weeks,  Karlsbad-Miihl- 
brunnen.  two  closes  of  one-half  glass  each  m  the  morning,  and 
Vichy-Celestins,  two  doses  of  one-half  glass  each  the  latter  part 
of  the  day.  She  improved  much,  led  a  somewhat  more  regular 
life  and  felt  comfortable  for  about  a  year  and  a  half;  then 
with  her  former  disorderly  habits  of  life  there  reajDpeared  the 
former  affections,  both  kmds  of  colics  and  particularly  the 
gouty  affections  of  the  bones  and  articulations  became  much  ag- 
gravated, and  nine  days  ago  patient  entered  our  clinic,  three 
years  after  her  fourth  sojourn  in  it. 

Status.  —  Patient  is  very  stout ;  the  color  of  the  skin,  for- 
merly normal,  is  at  present  dark,  olive-like.  The  appetite  is 
poor,  there  is  no  thirst;  patient  generally  drinks  sparingly. 
Slight  dyspeptic  phenomena,  as  pyrosis,  belching,  nausea,  appear 
only  when   the  diet  is   neglected,  otherwise  they   are    absent. 


—  233  — 

She  is  costive  ;  has  daily  stools,  but  insufficient  ones  ;  the  excre- 
tions are  normally  colored  by  bile.  The  abdomen  is  large  — 
from  an  evident  deposition  of  fat  as  well  as  from  intestinal  me- 
teorism.  Menstruation  appears  in  time,  but  is  small  in  quantity, 
lasting  only  one  day.  The  urine,  although  small  m  quantity  — 
900  c.  c.  —  is  pale  and  turbid;  the  sediment  contains  a  great  many 
crystals  of  oxalate  of  lime,  epithelial  cells  from  the  renal  pelvis, 
and  leucocytes  ;  albumen  and  sugar  absent.  The  kidneys  and 
the  ureters  are  very  sensitive.  The  liver  is  enlarged,  but  of 
normal  consistency  and  form,  and  is  not  tender ;  the  region  of 
the  gall-bladder  is  tender.  There  is  considerable  tenderness  in 
the  sternum,  ribs,  scapulae  and  vertebrae  ;  dyspnoea.  There  occur 
attacks  of  palpitation  with  slight  signs  of  angina  pectoris,  as  a 
sensation  of  oppression  at  the  side  of  the  heart  and  simulta- 
neously in  the  left  scapula  and  left  arm.  The  objective  examin- 
ation of  the  respiratory  tracts  elicits  nothing  abnormal.  There 
is  no  cough.  The  dimensions  of  the  heart  cannot  be  defined,  on 
account  of  the  great  thickness  of  the  subcutaneous  fat ;  its  tones 
are  clear,  but  very  weak ;  the  pulse  is  regular,  but  very  weak. 
At  present,  as  at  other  times,  there  is  no  fever ;  but  during  a 
cold  all  the  pains  become  aggravated,  and  at  such  times  the  pa- 
tient has  some  fever,  but  it  is  slight  and  of  short  duration. 
There  is  no  headache.  Dizziness  is  of  frequent  occurrence,  espe- 
cially when  she  gets  up  suddenly  or  stands  for  some  little  time, 
then  the  face  becomes  pale. 

The  sleep  is  always  very  poor  on  account  of  the  general  pains. 
For  the  last  year  slight  hysterical  attacks  began  to  appear  :  a 
sensation  of  oppression  in  the  chest  and  in  the  throat,  and  weep- 
ing ;  there  are  no  convulsions  or  loss  of  consciousness.  All  the 
bones  and  the  joints  of  the  extremities  are  more  or  less  sensi- 
tive ;  in  the  lower  ones  it  is  especially  the  joints  of  the  great 
toes,  in  the  upper  ones  it  is  the  shoulder-joints.  There  is  a  pro- 
nounced hyperaesthesia  cutis.  Hearing  and  sight  are  normal. 
Extreme  muscular  weakness.  The  legs  are  oedematous  up  to 
the  middle. 

Diagnosis  —  The  greater  part  of  the  affections  which  are 
observed  in  our  patient  were  already  discussed  by  us  m  con- 
nection with  the  foregoing  cases.     The  stomach  is  as  yet  in 


—  234  — 

good  condition.  The  costiveness  and  the  intestinal  meteorism 
■depend  on  the  weakened  condition  of  the  muscular  apparatus  of 
the  intestines,  so  natural  with  the  inactive  mode  of  life  and 
the  general  muscular  weakness  of  the  patient.  The  urinary 
tract  presents  signs  of  nephrolithiasis  and  of  catarrhal  pyelitis. 
There  are  biliary  calculi.  The  enlargement  of  the  liver,  in  the 
presence  of  insensitiveness  and  normal  consistency,  and  also  in 
view  of  the  general  obesity,  must  be  referred  to  a  fatty  condition 
of  this  organ ;  this  is  also  evidenced  by  the  olive  color  of  the 
skin,  which  points  to  some  difficulty  in  the  secretion  of  bile, 
caused  by  a  narrowing  of  the  biliary  passages  through  fatty  de- 
posits. The  weak  cardiac  activity,  as  seen  by  the  weak  pulse, 
dizziness  in  connection  with  a  pale  face  and  oedema  of  the  legs, 
in  the  presence  of  a  pulse  of  normal  frequency  and  of  normal 
rhythm,  must  be  ascribed  to  the  weakened  activity  of  the  cardiac 
muscle,  very  likely  due  to  a  fatty  condition  of  this  last ;  this  con- 
dition, in  connection  with  the  developed  hysterical  j)henomena, 
may  also  be  the  cause  of  the  slight  attacks  of  angina  pectoris 
and  of  palpitation.  The  dyspnoea,  in  the  presence  of  a  normal 
'condition  of  the  respiratory  tracts,  depends  evidently  also  on 
cardiac  weakness,  and  is  jDartly  due  to  the  high  position  of  the 
diaphragm  on  account  of  the  enlarged  abdomen.  The  slight 
hysteria  developed  in  our  patient  under  the  influence  of  an  in- 
active life  in  confinement,  contmuous  insomnia  and  prolonged 
severe  pains.  The  cutaneous  hypersesthesia  may  partly  be  due 
to  the  hysteria ;  however,  it  is  of  usual  occurrence  in  severely 
pamful  affections  of  subcutaneous  parts ;  the  hysteria  in  our  pa- 
tient is  slight,  whereas  the  cutaneous  hypersesthesia  is  extremely 
pronounced  and  is  observed  not  over  one-half  of  the  body,  as  is 
frequently  the  case  in  hysteria,  but  all  over,  and  particularly 
over  the  deep  painful  parts,  as  the  gall-bladder,  urinary  passages 
and  over  almost  all  the  bones  and  cartilages.  The  disturbances 
of  nutrition  are  very  typical  in  this  case :  under  the  influence 
of  the  above  depicted  mode  of  life  and  with  the  cessation  of 
pregnancies,  our  patient  developed  general  obesity,  later  typical 
gout,  arthritis  urica,  with  the  uric-acid  nephrolithiasis,  and  later 
still,  under  the  influence  of  muscular  inactivity  and  the  su- 
peradded functional  nervous  disturbances,    thanks    to  a  great 


—  235  — 

quantity  of  sweet  food,  there  appeared  oxahiria.  As  is  well 
known,  such  a  combination  of  disturbances  of  nutrition,  or  with 
the  addition  yet  of  diabetes  mellitus,  is  to  be  frequently  met  with. 

Prognosis.  —  The  condition  of  the  patient  is  evidently  very 
serious  :  in  the  presence  of  so  many  and  such  great  disturban- 
ces of  the  organism,  any  accidental  illness  —  of  no  consequence 
in  a  healthy  person  —  may  take  on  a  fatal  significance.  As  to 
what  concerns  the  cure,  or  at  least  a  considerable  improvement 
in  health,  even  this,  as  we  shall  see  later,  is  beset  with  great 
difficulties,  not  to  mention  the  patient's  weak  will,  which  para- 
lyzes all  our  efforts  in  the  direction  of  restoring  her  health  on  a 
durable  basis. 

Treatment  and  course  of  disease.  —  Diet,  watery  clysters,  in  ac- 
cord with  the  necessity  of  the  case,  and  stimulants  (a  mixture  of 
the  sether-valerianate  drops  with  the  Hoffman's  di'ops  with 
coffee).  At  the  beginning,  in  view  of  the  great  sensitiveness  of 
the  gall-bladder,  we  gave  calomel  in  eight  one-grain  powders,  one 
every  hour ;  this  brought  about  considerable  improvement,  but 
also  a  considerable,  although  only  temporary,  weakness,,  so  that 
we  had  to  give  up  the  further  use  of  calomel.  For  the  same 
reason,  after  the  first  warm  bath,  which  relieved  the  abdominal 
pams  —  those  of  the  kidneys  and  of  the  gall-bladder  —  but  which 
has  very  much  weakened  the  cardiac  activity,  we  were  also  com- 
pelled to  give  up  warm  baths.  Massage  of  the  affected  joints 
and  general  massage,  as  indicated  by  the  oxaluria,  even  if  very 
slight,  proved  to  be  impossible,  on  account  of  the  cutaneous 
hypereesthesia.  We  had  to  limit  ourselves  to  prescribing  the 
Contrexeville  water  —  for  the  oxaluria  —  in  half -glassful  doses 
three  times  a  day,  and  to  small  doses  (ten  grains  twice  or  three 
times  per  day,  but  not  every  day)  of  sodium  salycilate  as  a  pam- 
stillmg  agent,  and  fifteen  grains  of  sodium  bromide  at  bed-time 
(but  not  every  night)  as  a  somnifacient ;  both  drugs  were  ad- 
ministered in  the  above-mentioned  doses  of  Contrexeville  water ; 
but  this  relieved  the  patient  but  little ;  while  larger  doses  of 
the  salycilate  were  contra-indicated  by  the  weak  heart.  Contmu- 
ing  the  use  of  the  mineral  water  we  now  took  up  antipyrine,  in 
five-grain  doses  twice  a  day ;  this  acted  well  and  relieved  the 
pains  to  such  an  extent,  that  sleep  became  possible,  without 
weakening  the  cardiac  activity. 


—  236  — 

The  patient  left  the  clmic  October  27th,  markedly  relieved  in 
all  her  sufferings.  For  further  treatment  she  was  given  the 
foUowmg  advice :  while  resorting  as  far  as  necessary  to  watery 
clysters,  to  stimulant  and  pain-stillmg  drugs  (as  antipj'rme  and, 
later,  if  she  become  habituated  to  it,  phenacetine  in  the  same 
dosage),  she  must  drmk  alternately  Vichy-Celestins,  for  the 
uric-acid  deposits,  and  Contrexeville  for  oxaluria,  —  m  small 
quantity  (one  half-glassful  twice  a  day)  and  mtermittently, 
and  also  to  drmk  milk ;  when  possible  to  resort  to  massage,  as 
soon  as  the  pains  and  the  hypersesthesia  diminish,  and  to  warm 
baths,  when  the  weakness  is  diminished  and  durmg  the  warm 
season  of  the  year. 

The  treatment  by  milk  was  advised  as  follows  :  while  continu- 
ing the  di^inkmg  of  the  mentioned  mineral  waters,  and  while  re- 
sorting as  far  as  necessary  to  the  use  of  clysters,  of  stimulants 
and  anodynes,  durmg  the  days  of  the  milk  treatment  to  use,  be- 
sides milk,  only  coffee  with  some  sugar  and  a  little  tea  without 
sugar,  and  absolutely  nothing  more,  no  other  food  or  drmk ;  to 
drink  milk  which  is  neither  fat  nor  skimmed,  one  half-glassful 
at  a  time,  during  the  whole  day,  in  such  a  quantity  as  not  to 
feel  hungry,  but  not  more  than  this ;  it  is  ordinarily  sufficient 
to  drink  five  to  seven  glasses  per  day ;  to  drink  for  several  days 
at  a  stretch,  till  there  appears  a  feeling  of  weakness  ;  then  to 
leave  off  the  milk,  and  to  take  up  for  a  few  days  continuously 
another  food,  in  accord  generally  with  the  prescribed  diet ;  (va- 
rious foods  are  recommended  —  meat,  fish,  eggs,  and  also  starchy 
articles  ;  excluded — sweet  and  very  fatty  food,  as  well  as  various 
desserts,  sauces,  gravies,  etc.)  ;  as  soon  as  the  sensation  of  weak- 
ness will  pass  away  after  the  use  of  such  food,  then  return  at  once 
to  the  sole  use  of  milk  for  a  few  days,  until  a  satisfactory  result 
is  obtamed.  For  indications  for  this  treatment  by  milk  m  such 
cases,  I  refer  to  my  article  on  syphilis  of  the  heart.  I  will  add, 
that  in  cases  of  atonic  gout  similar  to  our  present  one,  when 
even  the  mmeral  waters  prove  ineffective,  or  effective  but  to  a 
slight  extent,  good  results  are  frequently  obtamed  by  a  continu- 
ous use  of  a  tea  made  of  herbs  and  root  of  fragaria  vesca  (straw- 
berry tea)  ;  for  a  pinch  of  this  tea  use  a  glass  of  boiling  water, 
let  it  steep  well  and  drmk  this  quantity  once  or  twice  a  day. 


DISEASES  OF  THE  KIDNEYS, 


SIXTEENTH   AND  SEVENTEENTH   CASES. 


LECTURE  OF  FEBRUARY   19,   1893. 

The  patient,  a  peasant,  age  thirtj-nine,  entered  the  clinic  one 
week  ago,  complammg  of  swelling  of  the  legs  and  face,  difdcul- 
tj  in  breathing,  headache  and  general  weakness. 

Mode  of  living  and  (mamnesis.  —  Patient  grew  up  in  a  village 
of  the  Moscow  Government,  but  has  been  living  in  Moscow  for 
a  long  time.  His  lodgmgs  are  rather  cold,  the  water-closet 
quite  so.  Takes  a  hot  bath  once  a  week.  Is  a  hard  smoker, 
has  been  an  intemperate  alcoholist  for  a  long  time  and  is 
addicted  to  drmking  hot  tea.  His  table  is  that  of  a  working- 
man.  He  is  married,  has  children ;  no  history  of  syphilis.  His 
occupation  is  that  of  a  machinist  in  a  prmting  establishment, 
his  work-day  from  7  A.  M.  to  8  P.  M.  (with  an  interval  of  one 
hour  for  dinner),  has  enough  tune  to  sleep,  but  not  much  of  an 
out^door  life. 

Until  ten  years  ago  patient  had  nothing  to  complain  of,  but 
later  began  to  observe,  after  drmking  heavily,  swelling  of  the 
legs  and  face,  which  would  pass  away  within  a  few  days  with- 
out treatment.  Some  six  years  ago,  also  after  a  debauch,  he 
spat  considerable  blood,  but  this  passed  without  leaA'ing  a  trace 
and  never  reappeared.  In  the  beginning  of  this  winter  there 
appeared  the  usual  oedema  of  the  face  and  of  the  legs,  l^ut  it 
did  not  pass  away ;  and  recently  it  increased  and  to  it  was 
superadded  a  slight  enlargement  of  the  abdomen,  diarrhoea, 
dyspnoea,  headache  and  general  weakness,  all  of  which  com- 
pelled him  to  seek  medical  aid  in  the  clinic. 

During  a  week's  sojourn  in  the  clinic,  patient  began  to  im- 
prove markedly,  thanks  to  the  warm  room  and  to   the  warm 

237 


—  238  — 

water-closet,  to  rest  in  a  comfortable  bed  and  to  the  use  of 
.strong  wine  (six  tablespoonfuls  per  day),  and  of  the  stimulant 
drops  (tra.  valer.  seth.  and  liqu.  anod.  Hoffm.  aa  gttas.  xxv,  four 
times  a  day),  his  food  consisting  of  milk  (boiled,  in  view  of  a 
tendency  to  diarrhoea),  milk  soup  of  grits  (semolino)  and 
chicken  soup. 

Status.  —  The  appetite  is  better  than  it  was  on  admission,  the 
former  diarrhoea  ceased.  The  liver  and  spleen  present  nothing 
abnormal.  The  region  of  the  kidneys  is  somewhat  tender  on 
pressure.  On  admission  to  the  clinic  his  urine  amounted  to 
500  c.c.  for  the  twenty-four  hours,  containing  0.3  per  cent,  of 
albumen  by  Essbach's  albuminometer,  and  a  sediment  consisting 
of  a  few  granular  cylinders  and  red  blood-corpuscles,  and  many 
leucocytes;  the  quantity  of  urine  is  now  2000  c.c.  with  0.2  per 
cent,  of  albumen,  a  few  leucocytes  and  with  almost  no  cylinders 
and  red  blood-corpuscles  ;  some  accumulation  of  fluid  can  be  ob- 
served in  the  abdominal  cavity.  The  dj^spncea,  although  easier, 
is  still  considerable ;  there  is  a  slight  cough  with  some  expecto- 
ration ;  objective  exammation  of  the  respiratory  tracts  elicits 
nothing  abnormal,  outside  of  some  dry  rales  here  and  there. 
The  heart  is  enlarged :  the  apex  beat  is  felt  one  finger's  width 
to  the  left  of  the  left  mammillary  line,  and  the  sound  on  the  in- 
ferior part  of  the  sternum  is  markedly  duller  than  on  the  superior; 
the  tones  are  clear.  The  pulse  is  88,  of  regular  rhythm,  but 
somewhat  weak ;  still  it  is  already  stronger  than  it  was  a  week 
ago.  The  oedema  of  the  legs  and  of  the  face  diminished  some- 
what. There  is  no  fever.  Sleep  is  prevented  by  pains  in  the 
head  which,  although  quite  severe  as  yet,  have  abated  some. 
The  general  weakness  is  less  at  present. 

Before  we  turn  to  the  diagnosis  and  treatment  of  this  case, 
I  will  present  to  you  another  for  a  parallel  investigation.  This 
patient,  a  peasant  woman,  thirtj^-nine  years  old,  entered  our 
clinic  October  31st,  1892,  complaining  of  considerable  swelling 
in  the  face,  legs  and  abdomen,  of  extreme  dyspnoea,  of  cough, 
constant  headache,  and  extreme  weakness. 

Mode  of  living  mid  anamnesis.  —  The  patient  is  a  constant  re- 
sident of  a  village  in  the  government  of  Moscow,  situated  in  a 
very  damp  locality.  She  lodges  in  an  ordinary  peasant's  hut,  with  ' 


—  239  — 

a  water-closet  in  the  barn.  Patient  takes  a  weekly  steam-bath  over 
an  oven,  after  which  she  clashes  water  over  herself  standing  at 
the  front  of  the  house,  even  in  winter.*  jS'ever  drank  any  whiskey 
or  wine  —  drmks  a  great  deal  of  tea ;  food,  ordmarj^  peasant's. 
Patient  is  a  widow,  had  neither  children  nor  any  miscarriages. 
Judgmg  from  her  anamnesis  as  well  as  her  present  condition, 
sjiDhilis  may  be  excluded.     She  does  house-work  and  field-labor. 

Until  the  last  five  j^ears  our  patient  always  enjoyed  good 
health.  Five  years  ago  there  appeared  for  the  first  time  swel- 
ling of  the  legs  and  face,  which  passed  away  in  the  course  of 
two  weeks  without  any  treatment.  Since  then  the  eyelids  would 
swell  occasionally.  Last  August  the  legs  and  face  became 
swollen  ;  during  autuimi  and  winter  the  swelling  continued  in- 
creasing and  the  abdomen  began  to  enlarge  very  markedly ;  to 
this  were  soon  added  headaches,  general  weakness,  dyspnoea 
and  cough,  and  at  times  a  diarrhoea  of  abundant  fluid  evacua- 
tions, accompanied  now  and  then  by  slight  pain  in  the  abdomen. 

Patient  has  beenm  the  clinic  for  the  last  three  and  a  half 
months.  Her  surroundings  and  diet  were  the  same  as  m  the 
foregomg  case,  but  on  account  of  the  diarrhoea,  milk  was  given 
in  small  quantities  —  two  and  a  half  glasses  during  the  twenty- 
four  hours.  The  treatment  was  as  follows :  the  looseness  of 
the  bowels  was  kept  under  control,  but  not  stopped  suddenly, 
first,  because  it  could  assist  in  decreasing  the  oedema  and  espe- 
cially the  abdommal  dropsy,  which  was  very  considerable,  as  we 
shall  see  later,  and  secondly,  because  the  dyspnoea,  caused  b}^ 
the  oedema  of  the  lungs  and  by  uraemia,  of  which  we  will 
speak  later,  would  become  intolerable  if  the  patient  were  con- 
stipated. To  modify  the  diarrhoea,  which  took  place  occasion- 
ally, and  not  to  check  it  suddenly,  fifteen  drops  of  tra.  coto,  thi-ee 
times  a  day,  proved  to  be  sufficient ;  opium,  which  is  generally 
not  indicated  m  cases  of  chronic,  slightly  painful  diarrhoea,  is  ev- 
idently contra-indicated  in  the  present  case  by  the  general  weak- 
ness as  well  as  by  that  of  the  heart,  but  especially  by  oedema 
of  the  lungs.  To  strengthen  the  cardiac  activity  we  gave  the 
same    drops  as  in  the  foregoing  case,  twenty-five  drops  three 

*  A  custom  prevalent  among  a  great  iDart  of  the  Paissian  peasantry.  — 
Note  of  the  translator. 


—  240  — 

times  per  day ;  we  were  compelled  to  discontinue  the  use  of 
wine,  as  it  tended  to  aggravate  greatly  the  pains  in  the  head. 
When  the  latter  became  very  severe  we  resorted  at  times  with 
success  to  five-grain  doses  of  phenacetine.  As  a  diuretic  we 
tried  at  first  diuretin  (theobrominum  natrobenzoicum,  3j  in  3vj 
of  aqua  destil.,  in  tablespoonful  doses),  but  had  to  give  it  up 
after  the  fifth  dose,  as  it  increased  the  headache  and  caused 
nausea  and  vomiting.  For  the  same  reason  we  left  off  caffeuium 
nitrobenzoicum,  which  we  prescribed  after  the  diuretin  in  five- 
grain  doses  three  times  per  day.  We  then  gave  her  calomel, 
which  was  administered  in  one  grain  doses  four  times  a  day  and 
was  well  borne,  without  increasing  the  diarrhoea  ;  but  it  did  not 
in  the  least  increase  the  quantity  of  the.  urme  nor  relieve  the 
ursemic  phenomena  (the  headaches),  and  it  also  was  therefore 
given  up.  We  have  had  thus  to  limit  ourselves,  for  purposes 
of  acting  upon  the  kidnej^s,  to  the  employment  of  baths  since 
the  end  of  November.  The  patient,  who  has  acquired  of  late  a 
susceptibility  to  cold,  felt  chilly  in  a  bath  at  the  temperature 
of  30°i2.  (99.5°i^.)  and  31°i2.  (101.7°i^.);but  at  32°i?.  (104°i^.) 
and  laterat  33°i?.  (106.2°  i^.)  the  bath  mduced  an  agreeabl}^  warm 
sensation.  The  patient  had  such  baths,  with  slight  interrup- 
tions, from  the  time  she  entered  the  clinic  until  December  10th  ; 
they  brought  about  a  slight  improvement,  the  quantity  of  urine 
bemg  increased  temporarily  and  all  the  morbid  phenomena  hav- 
ing diminished;  but  tills  improvement  was  rather  unstable  and 
passed  off  rapidly,  so  that  by  December  10th  the  average  quanti- 
ty of  the  urine  was  about  the  same  as  when  she  was  admitted, 
about  1200  c.c.  in  twenty-four  hours,  and  the  condition  of  the 
patient  improved  but  little.  From  that  date  on,  we  began  the 
employment  of  dry  hot-air  baths,  from  4:5° E.  (1SS.5°F.)  to  60° J?. 
(167°^.),  in  an  apparatus  conveniently  applied,  as  you  see,  to 
the  bed ;  these  batlis  called  out  profuse  perspirations,  and  the 
condition  of  the  patient  began  to  improve  steadily  smce ;  by 
January  10th  the  amount  of  urine  was  increased  to  2000  c.c.  in 
twenty-four  hours,  by  February  10th  to  3000,  which  amount  re- 
mains at  present ;  the  oedema  and  the  ascites  have  also  dimm- 
ished  greatly,  and  the  patient  has  since  enjoyed  the  good  condi- 
tion ui  which  you  find  her  now. 


—  241  — 

Status.  —  The  appetite,  which  was  poor  on  the  patient's 
admission  to  the  clinic,  is  good  now.  Tlie  dyspeptic  phenom- 
ena, as  heaviness  in  the  stomach  and  belching,  also  nausea  and 
vomiting  accompanied  by  severe  headache  evidently  of  ursemic 
origin,  observed  on  her  admission,  have  passed  away ;  so  has, 
since  the  middle  of  December,  the  diarrhoea.  Ascites  is  not 
apparent  at  present:  the  circumference  of  the  abdomen  on  a 
level  with  the  umbilicus  was  172  cm.  before,  but  at  present  is 
89  cm.  The  hver  and  the  spleen,  which  did  not  admit  of  pal- 
pation on  patient's  admission,  present  on  examination  notlimg 
abnormal  now.  No  menstruation  smce  August ;  it  was  former- 
ly regular  and  painless  ;  she  never  had  any  leucorrhoea  ;  the  gy- 
naecological examination  shows  that  the  climacteric  period  is 
approaching.  The  quantity  of  urine  on  admission  was  1,000 
c.c.  in  the  twenty-four  hours,  red,  turbid,  with  an  abundant  sedi- 
ment, consisting  of  a  great  quantity  of  renal  epithelium,  granular 
hyaline  cylinders,  red  blood-corpuscles  and  leucocytes;  there  was 
0.6  per  cent,  of  albumen  ;  the  amount  of  urine  is  at  present  3,000 
c.c,  it  is  pale,  slightly  turbid,  with  a  trifling  sediment,  in  which 
the  quantity  of  the  above-named  elements  is  much  smaller, 
while  the  red  blood-corpuscles,  the  renal  epithelium  and  the 
epithelial  cylinders  are  absent  altogether;  there  is  onl}^  0.2  per 
cent,  of  albumen.  When  admitted,  patient  was  suffermg  from 
a  severe  dyspnoea,  which  would  not  allow  of  sleepmg  in  a  re- 
cumbent posture,  and  a  severe  cough,  that  would  raise  with  con- 
siderable difficulty  a  small  quantity  of  expectorated  matter, 
accompanied  by  mucous  rales  in  the  inferior  portions  of  the 
lungs ;  at  present  the  rales,  as  well  as  the  cough  and  dyspnoea, 
have  almost  disappeared,  and  the  patient  is  able  to  sleep  in  a 
recumbent  posture.  The  apex  impulse,  which  could  not  be 
palpated  on  her  admission,  is  clearly  felt  now  along  the  left 
mammillary  line  ;  at  the  same  time  the  pulse,  which  was  former- 
ly very  weak,  although  not  quite  frequent  (80)  and  rhythmical, 
became  stronger  and  less  frequent  (72  to  76),  the  sound  over  the 
sternum  is  everywhere  clear,  the  tones  of  the  heart  clear.  The 
formerly  enormous  oedema  has  almost  disappeared;  there  re- 
mains yet  some  on  the  legs.  Fever  neither  before  nor  now. 
Patient,  formerly  very  pale,  is  not  so  pale  now.     The  sleep, 


—  242  — 

which  was  formerly  prevented  by  headaches  and  the  patient's 
inability  to  sleep  in  a  recumbent  position,  is  now  good :  the  head- 
aches are  less  frequent  and  milder,  the  general  weakness  is 
much  less. 

These  gathered  data  will  certamly  make  it  clear  to  you,  that 
it  is  the  kidneys  which  are  principally  affected  m  both  cases, 
and  that  the  morbid  processes  are  of  a  chronic  nature.  Enter- 
ing to-day  on  the  discussion  of  diseases  of  the  kidneys,  namely, 
chronic  ones  (as  there  do  not  happen  to  be  in  the  clinic  just  at 
present  any  pure  cases  of  acute  nephritis),  I  selected  from  among 
the  clinical  patients  the  two  whom  I  presented  before  you,  be- 
cause I  considered  their  clinical  analysis,  conducted  along  paral- 
lel lines,  as  particularly  useful  in  acquamtmg  you  with  the 
chronic  nephrites  ;  but  before  going  any  further,  before  consider- 
ing the  diagnosis  and  the  treatment  of  both  cases,  I  think  it 
necessary  to  take  a  brief  survey  of  the  varieties  of  chronic 
nephritis  recognized  by  modern  pathology. 

Pathological  anatom}^  has  proved  that  a  chronic  nephritis  is 
always  the  same  in  the  sense,  that  there  always  takes  place  a 
contemporaneous  affection  of  the  glandular  element,  —  the  urin- 
ary tubules,  —  and  of  the  interstitial  substance,  but  that  in  a 
great  number  of  the  cases  one  or  the  other  of  the  affections  is 
more  predominating.  The  clinical  data  prove,  that  the  variety  of 
the  disease  and  its  course  in  cases  in  which  the  affection  of  the 
glandular  tissue  predominates,  are  clearly  distmct  from  the  va- 
riety and  course  of  the  disease  with  a  predominance  of  the  affec- 
tion ofthe  interstitial  tissue,  and  the  clinic  therefore  distinguishes 
two  varieties  of  chronic  nephritis  :  the  parenchymatous  and  the 
interstitial.  In  the  interstitial  variety  there  is  a  great  quantity 
of  pale  and  limpid  urine  with  a  trifling  sediment,  consisting 
usually,  although  not  constantly,  of  hyaline  cylinders,  the  albu- 
minuria is  inconsiderable  and  inconstant ;  the  various  oedemata 
are  either  absent,  or  there  ma}^  be  some  slight  oedema  of  the 
legs,  while  the  left  ventricle  of  the  heart  is  hj^pertrophied  and 
usually  dilated.  In  parenchymatous  nephritis  the  urine  is 
scanty,  very  turbid,  and  gives  a  considerable  sediment,  contain- 
ing leucocytes,  frequently  also  red  blood-corpuscles,  renal  epithe- 
lium and  epithelial,  granular  and  hyaline  cylinders ;  the  albu- 


—  243  — 

minuria  is  considerable;  with  this  there  occur  severe  anasarca  and 
accumulations  in  the  cavities,  and  a  frequently  recui'ring,  ob- 
stinate diarrhoea,  while  the  left  ventricle  of  the  heart,  although 
enlarged  (dilated),  is  not  at  all,  or  very  little,  hypertrophied, 
probably  because  the  nutrition  of  such  patients  fails  rapidly, 
whereas  the  nutrition  of  patients  suffermg  with  mterstitial  neph- 
ritis may  remain  for  a  long  time  in  a  good  condition. 

In  interstitial  nephritis  death  is  brought  about  either  by  apo- 
plexy in  the  brain,  caused  by  hypertrophy  of  the  dilated  left 
ventricle  in  conjunction  with  a  chronic  arteritis,  or  even  an 
atheromatous  condition  of  the  arteries  ;  or  by  uraemia,  or  through 
disturbances  of  compensation  (when  the  heart  is  further  affected) 
or  through  inflammation  of  the  mucous  membranes,  to  which  last 
these  patients  are  so  predisposed.  Parenchymatous  nephritis 
causes  death  through  ascites  and  ui^aemia,  as  well  as  through  the 
above-named  mflammations,  to  which  such  patients  are  even 
more  predisposed.  Both  varieties  of  the  fully  developed  nephri- 
tis are  incurable;  but  patients  with  interstitial  nepliiitis,  enjoy- 
ing moderately  good  health,  may  live  for  a  long  time,  much  over 
ten  years,  while  those  with  the  parenchymatous  variety  will  only 
live  a  few  years  and  that  in  a  condition  of  great  debility  and 
severe  suffering.  Prognosis  is  therefore  worse  for  cases  of  pa- 
renchymatous, than  for  those  of  mterstitial  nephritis.  In  the 
course  of  both  varieties  of  chronic  nephritis  there  take  place 
changes  which  point  to  their  close  relationship,  to  the  fact, 
that  they  belong  to  one  process. 

In  interstitial  nephritis  the  urine  will  frequently  diminish  in 
quantity  all  of  a  sudden,  become  turbid,  throwing  down  an  abun- 
dant sediment,  containing  the  same  formative  elements,  as  it 
does  in  parenchymatous  nephritis,  and  show  a  great  quantity 
of  albumen,  and  at  the  same  time  there  will  appear  considerable 
oedema ;  but  all  these  phenomena  will  pass  away  rapidly  in  a 
few  days  under  correct  regimen  and  treatment  (usually  cardiac 
stimulants  and  warm  baths),  and  the  physician  —  certainly,  the 
one  who  is  very  unexperienced  or  rather  careless  —  who 
first  saw  the  patient  in  the  above-depicted  condition  of  exacer- 
bation, will  be  compelled  later  on  to  change  his  diagnosis  (and 
consequenily  also  the  prognosis),  and  instead  of  what  seemed  to 


—  244  — 

him  a  parenchymatous  nephritis,  will  recognize  "  an  exacerba- 
tion "  of  the  interstitial  variety.  It  is  true,  that  this  "exa- 
cerbation "  is  in  reality  but  a  rapidly  passing  parenchymatous 
inflammation,  com  plicating  the  original  variety ;  but  this  ori- 
ginal variety,  with  all  the  peculiarities  in  its  course  and  termina- 
tion, and  consequently  in  the  prognosis,  is  in  such  cases  after 
all  an  interstitial  nepliritis.  Such  "  exacerbations  "  of  intersti- 
tial nephritis  may  pass  away  even  if  untreated,  as  is  seen,  for  in- 
stance, from  the  history  of  our  first  patient. 

Parenchymatous  nephritis  terminates  in  the  majority  of  cases 
fatally ;  but  at  times,  rather  rarely  however,  a  more  favorable 
termination  takes  place,  which  is  known  as  the  "  transition  into 
interstitial  nephritis"  :  thus  the  amount  of  urine  increases,  its 
turbidity,  the  sediment  of  abundant  formative  elements  and  the 
considerable  albuminuria,  all  these  bemg  the  chief  symptoms 
of  a  severe  affection  of  the  renal  parenchyma,  decrease  and 
become  insignificant.  Alongside  with  these  the  various  oede- 
mata and  exudations  into  the  cavities  disappear,  the  diarrhoea 
ceases,  while  the  nutrition  improves,  the  patient  gathers 
strength,  and  there  is  developed  a  hypertrophy  of  the  left 
ventricle  of  the  heart;  thus  the  picture  of  a  typical  paren- 
chymatous nephritis  changes  to  that  of  a  typical  interstitial 
variety  with  its  more  benign  course.  It  becomes  evident,  that 
this  "transition  of  a  parenchymatous  nephritis  into  an  in- 
terstitial" is  but  the  cessation  or  extreme  diminution  of  the 
more  dangerous  parenchymatous  process,  and  a  continuation, 
in  the  form  of  a  further  extension,  of  the  interstitial  variety, 
which  always  accompanies  the  parenchymatous  form. 

Diagnosis.  —  From  the  above  it  becomes  apparent,  that  our 
first  patient  suffers  from  a  chronic  interstitial  nephritis  (as 
evidenced  by  the  fact,  that  the  disease  had  existed  for  ten 
years,  that  the  oedemata  are  of  a  slight  and  rapidly  passing 
character,  and  that  the  heart  is  enlarged)  with  an  occasional 
"  exacerbation,"  i,  e.  complicated  by  a  rapidly  passing  inflam- 
mation of  the  renal  parenchyma.  That  this  last  is  of  a  rapidly 
passing  nature  is  seen  by  the  rapid  improvement  m  the  patient's 
condition :  during  the  course  of  one  week,  with  the  aid  of  a 
correct  regimen  and  the  emplojonent  only  of  cardiac  stimulants, 


—  245  — 

even  without  warm  baths,  the  quantity  of  urine  was  raised 
from  500  c.e.  in  the  twenty-four  hours  to  2000,  and  the  forma- 
tive elements  in  the  urinary  sediment  began  to  disappear.  For 
the  sake  of  completness  in  the  diagnosis  we  must  say  a  few 
words  on  the  condition  of  the  heart ;  its  dilatation  is  indicated 
by  its  enlargement:  the  dilatation  of  the  left  ventricle,  as  ap- 
parent from  the  long  duration  of  the  disease,  is  of  a  permanent 
nature,  while  the  dilatation  of  the  right  one  (as  can  be  judged 
by  the  dull  sound  on  the  inferior  portion  of  the  sternum)  is 
probably  of  a  temporary  character,  dependent  on  the  weakened 
activity  of  the  heart,  and  is  likely  to  diminish  with  the  improve- 
ment of  the  latter.  The  rapid  increase  in  the  quantity  of  the 
urine  points  to  a  hypertrophy  of  the  left  ventricle.  The  dys- 
pnoea, headache  and  insonuiia,  which  appeared  together  with  the 
developed  cedema  and  the  diminished  quantity  of  the  urine, 
and  which  decrease  with  the  increase  in  the  amount  of  this 
last,  are  evidently  of  an  ursemic  character. 

Our  second  patient,  from  what  we  are  led  to  judge  by  the  above- 
mentioned  two  varieties  of  chronic  nephritis,  presents  not  a  rapid- 
ly passing  inflammation  of  the  renal  parenchyma  that  occurs  in- 
cidentally during  the  course  of  a  chronic  interstitial  nephritis, 
but  a  firmly  established  parenchymatous  nephritis ;  this  is  in- 
dicated not  only  by  the  characteristic  picture  of  the  disease, 
as  by  obstinate  dropsical  phenomena  of  anasarca,  ascites  and 
cedema  pulmonum,  by  persistent  diarrhoea,  characteristic  urine, 
and  the  condition  of  the  heart,  but  also  by  the  unyielding  nature 
of  the  disease  to  treatment :  warm,  and  even  hot  water-baths 
at  the  temperature  of  32°  (104°  F.)  to  33°  R.  (106.2°  i^.) 
employed  durmg  a  whole  month,  failed  to  bring  about  the 
lea.st  improvement  in  the  patient's  condition,  and  only  ener- 
getic application  of  air-baths  at  a  high  temperature  induced  a 
decided  turn  for  the  better. 

Prognosis.  — As  seen  from  the  course  of  the  disease  and  its 
treatment,  we  may  hope  in  the  first  case  for  a  speedy  disap- 
pearence  of  the  "exacerbation  "  and  for  the  return  of  the  patient 
to  his  ordinary  tolerable  condition  of  health,  while  in  the  second 
case  we  may  expect  the  "  transition  "  of  the  disease  into  a  toler- 
able condition  of  interstitial  nephritis,  i.  e.  the  cessation  of  the 
more  dangerous~parenchymatous  process. 


—  246  — 

From  the  analj^sis  of  these  two  patients  aud  from  their 
further  observation  you  will  become  acquainted  with  typical 
cases  of  both  varieties  of  chronic  nephritis  and  with  the  most 
important  changes  in  their  courses  and  also  with  the  most  effi- 
cient means  for  their  treatment. 

Treatment.  —  We  gave  as  yet  no  hot  baths  to  our  first  patient 
on  account  of  his  weakness,  while  internall}^  he  was  given  stimu- 
lant drops  in  view  of  the  diarrhoea.  At  present  the  patient 
is  somewhat  stronger  and  we  will  therefore  order  for  him  some 
baths  and  internalh^,  outside  the  above-mentioned  stimulant 
di'ops  (for  the  diarrhoea  stopped),  also  some  caffeine,  as  a  diuretic 
which  acts  through  the  heart,  by  strengthening  the  latter's  ac- 
tivity ;  as  a  diuretic  agent  on  the  kidneys,  we  have  only  milk : 
the  "  strong"  diuretics  are  contraindicated  by  the  condition  of  the 
kidneys,  while  the  less  irritating  ones  —  as  the  alkaline  mineral 
waters,  —  cannot  be  used  on  account  of  the  only  recently  ceased 
diarrhoea.  The  mdication  for  prescribmg  caffeine  —  in  the  con- 
dition of  cardiac  activity  as  observed  in  the  present  case  —  for 
its  diuretic  effect  through  the  heart,  and  no  other  •■'  cardiac  " 
drug,  is  certainly  sufficiently  clear  to  you  now,  but  it  will  be- 
come clearer  still,  when,  m  analj^zing  clinically  diseases  of  the 
heart,  we  will  discuss  the  comparative  eff'ect  of  different  cardiac 
drugs.  In  the  second  case,  after  what  was  shown  by  its  obser- 
vation, we  must  continue  the  air-baths  at  a  high  temperature 
and  also  the  stimulatmg  drops.  For  internal  use,  in  view  of 
the  patient's  pallor,  there  is  an  indication  for  iron ;  arsenic  is 
contra-indicated,  outside  of  other  considerations,  by  the  former 
obstinate  diarrhoea. 


The  male  patient  left  the  clinic  ^larch  11th.  From  February 
19th  to  March  6th  he  was  given  seven  baths  at  the  temperature 
of  31°it.  (about  101.7°i^.)  ;  mternally  he  was  given  from  Feb- 
ruary 19th  to  the  2Tth  caffeine  natrobenzoate  (in  five-gram  doses, 
at  first  twice  a  day,  and  later  three,  four  and  five  times),  and 
from  February  27th  to  March  6th  he  had  theobromine  natroben- 
zoate, in  drachm  quantities  daily  (3j  in  fij  of  water,  in  table- 
spoonful  doses).  There  was  no  appreciable  difference  in  the 
action  of  either  of  the  drugs,  but,  as  is  well  known,  and  as  you 


—  247  — 

may  also  judge  by  the  present  case,  we  have  to  give  greater 
quantities  of  theobromine  than  of  caffeine  ;  and  the  first  costs 
more  than  the  second.  Already  by  March  6th  the  principal 
morbid  phenomena,  as  the  oedemata,  the  dyspnoea,  headache, 
insomnia  and  weakness,  disappeared,  and  the  amount  of  urine 
increased^  the  patient  left  the  clinic  strengthened,  suffering 
with  a  trifling  albuminuria  and  an  enlarged,  but  functionally 
efficient  left  ventricle  of  the  heart ;  the  right  ventricle  has  evi- 
dently returned  to  its  normal  dimensions,  as  the  sound  on  the 
inferior  part  of  the  sternum  became  clear.  Our  advice  to  the  pa- 
tient when  leaving :  not  to  abuse  brandy  and  hot  tea,  not  to  go 
during  the  cold  season  of  the  year  into  a  cold  water-closet,  nor 
to  take  a  steam-bath  in  winter,  and  to  wear  woolen  undergar- 
ments. 

The  female  patient  left  the  clinic  April  17th.  The  very 
small  quantity  of  iron  (tinctura  tonico-nervina  Bestujeff,  * 
five  drops  three  times  a  day)  which  was  prescribed  for  her  Feb- 
ruary 23d  caused  a  diarrhoea  on  the  very  next  day  and  it  was 
therefore  discontinued.  Under  the  use  of  tra.  coto  the  diar- 
rhfjea  soon  ceased.  The  treatment  then  consisted  of  the  use  of 
air-baths  at  a  high  temperature,  together  with  the  use  of  stimu- 
lating drops.  By  the  begmning  of  April  the  baths  became  un- 
necessary: the  anasarca,  ascites  and  the  cedema  of  the  lungs 
passed  away,  there  was  no  recurrence  of  the  diarrhoea,  the  head- 
ache and  insomnia  disappeared,  the  patient  left  the  clinic  with 
an  albuminuria  (0.2  per  cent),  but  very  much  strengthened  and 
with  a  functionally  active  heart.  Our  advice  on  taking  her 
leave  :  to  take  no  steam-baths  over  the  oven,  nor  dash  any  water 
over  the  body  during  a  frost,  and  to  wear  woolen  undergarments 
(with  this  last,  being  indigent,  she  was  supplied  from  the 
clinic). 

*  Solution  of  chloride  of  Iron  (U.S.P)  .         .         850  min. 

Stronger  ether 4  fl.  oz. 

Alcohol,  enough  to  make  .         .         .         .  16  fi.  oz. 

Each  fluidrachm  contains  about  Yz  gr.  of  metallic  Iron. 

(U.  S.  D.) 


ANAEMIAE. 


SEVENTEENTH  CASE. 


LECTURE  OF  MARCH   16,  1893. 

The  patient,  a  merchant's  wife,  age  twenty,  not  desiring  to 
enter  the  clinic,  is  being  treated  at  hoine  and  comes  here  only 
for  advice.  She  first  applied  here  one  week  ago,  complaining 
of  difficulty  in  breathing,  palpitation  of  the  heart  and  dizziness 
on  moving  around,  a  constant  noise  in  the  head,  general  weak- 
ness and  a  slight  oedema  of  the  face  and  lower  extremities. 

Mode  of  living  and  anajiinesis.  —  Patient  moved  two  weeks  ago 
to  Moscow,  into  a  good  residence,  and  before  this  she  lived  in  a 
healthy  country  locality,  also  in  a  good  house.  Is  not  used  to 
sea-bathing,  but  takes  a  bath  (in  the  public  bath-house)  weekly. 
Does  not  smoke,  drinks  neither  wine  nor  coffee,  and  but  a  little 
tea.  Has  good  meals  (fish  on  fast-days).  Her  occupation  is 
light,  of  a  household  nature,  but  fatiguing  on  account  of  her 
weakness,  this  last  also  keeping  her  most  of  the  time  in-doors. 
Was  married  two  months  ago. 

The  patient  enjoyed  good  health  until  last  summer,  but  on 
account  of  the  cholera  epidemic  she  spent  that  summer  in  a 
condition  of  great  mental  anxiety  and  suffered  also  a  severe 
shock  from  the  loss,  by  cholera,  of  persons  dear  to  her.  Since 
autumn  the  patient  began  to  grow  pale  and  weak ;  and  during 
December  the  above-enumerated  morbid  phenomena  made  their 
appearance  and  since  her  marriage  have  become  particularly  ag- 
gravated. 

Status.  —  The  patient,  as  you  see,  is  of  average  constitution 

and  very  pale,  while  a  week  ago  the  pallor  was  striking  and  had 

a  greenish  tint.     The  pallor,  as  well  as  the  (jedema  of  the  legs 

and  face,  have  decreased  considerably  for  the  last  week,  because 

248 


—  249  — 

the  patient  began  taking  iron,  which  we  prescribed  for  her  in  the 
clinic.  Up  to  the  time  that  she  began  taking  iron  her  appetite 
was  poor  and  she  suffered  from  nausea  after  meals  ;  the  appetite 
is  now  better  and  the  nausea  disappeared.  She  is  costive,  but 
watery  clysters  empty  the  bowels  sufficiently.  The  urine  is 
pale,  of  a  specific  gravity  of  1007,  but  contains  neither  albumen 
nor  sugar,  nor  peptones.  The  liver,  the  spleen  and  the  abdomen 
in  general  present  nothing  abnormal.  Menstruation  appeared 
first  when  she  was  seventeen  years  old  and  had  been  quite  reg- 
ular formerly,  but  since  summer  it  began  to  appear  once  in 
three  months  and  very  scantily,  last  time  in  December  ;  it  was 
always  painless.  Gynaecological  examination  shows  the  uterus 
rather  under-developed,  considering  patient's  age. 

Both  the  dyspnoea '  and  palpitation  are  now  less  than  they 
were  a  week  ago.  The  respiratory  organs  are  in  a  normal  con- 
dition. The  dimensions  of  the  heart  are  normal.  All  over  the 
region  of  the  heart  there  is  heard  a  systolic  murmur,  while  over 
the  veins  of  the  neck  the  murmur  is  constant.  The  number 
of  the  red  blood-corpuscles  is  50  per  cent,  of  the  normal,  of 
the  haemoglobin  but  12  per  cent,  of  the  normal  quantity  ;  there  is 
neither  poikilocytosis  nor  leucocytosis.  The  pulse  is  80,  as 
yet  weak,  but  already  stronger  than  formerly.  Patient  is  not 
feverish.  The  sleep  is  fair.  She  complains  less  of  noise  in  the 
head,  of  dizziness  and  general  debility. 

Diagnosis.  —  We  evidently  have  .here  before  us  a  typical  ease 
of  chlorosis  in  its  extreme  development.  No  part  of  the 
organism,  outside  of  the  blood  and  the  sexual  apparatus,  pre- 
sents any  signs  of  a  primary  affection :  the  observed  morbid 
phenomena,  which  in  their  entirety  form  such  a  complete  pic- 
ture of  chlorosis,  depend  apparently  on  a  clearly  pronounced 
alteration  in  the  blood  ;  the  systolic  murmur  in  the  region  of  the 
heart  in  the  presence  of  normal  dimensions  of  this  last  depends  cer- 
tainly on  the  same  cause.  Pernicious  anaemia  may  be  excluded 
b}"  the  absence  of  any  signs  of  increased  disintegration  of  the  red 
blood-corpuscles,  namely  the  absence  of  poikilocytosis,  pepto- 
nuria and  urine  of  a  high  specific  gravity ;  against  leukaemia 
speaks  the  absence  of  leucocytosis  and  of  symptoms  of  any 
affection  of  the  spleen  and  of  the  lymphatic  glands ;  this  last 


—  250  -^ 

also  excludes  pseudo-leuksemia ;  that  the  disease  is  not  an  anae- 
mia resultmg  from  failure  in  nutrition  and  hsemotopoiesis  as 
due  to  unfavorable  conditions  of  life,  is  evidenced  by  the  fact, 
that  the  disease  developed  under  the  identical  material  con- 
ditions, under  which  her  health  was  formerly  satisfactory,  while 
a  depressed  mental  state  —  as  in  the  present  case  — is  shown  by 
experience  to  favor  the  development  of  just  the  condition  of 
chlorosis. 

What  is  the  nature  of  chlorosis  ?  The  investigation  of  this 
question  lies  outside  of  the  domain  of  clinical  exercises  proper, 
as  conducted  for  beginners,  but  I  consider  it  important  to  take 
it  up  now,  so  that  we  may  define  the  disease  more  fully  and 
consequently  be  able  to  distinguish  it  with  greater  precision 
from  other  cases  of  ansemia  that  we  may  run  across  later 
on. 

In  the  text-books  of  internal  pathology  chlorosis  is  described  in 
the  part  treating  of  diseases  of  the  blood ;  but  this  part  forms 
one  of  the  weakest  features  of  every  text-book.  Let  us  take, 
for  example,  the  well-known  German  text-book  of  Eichhorst, 
translated  into  the  most  important  European  languages : 
."  Chapter  VIII.  Diseases  of  the  blood  and  of  the  hlood forming 
organs.  Part  first.  Diseases  of  the  blood.''"'  And  now,  without 
any  explanatory  introduction,  there  follow  one  after  the  other 
descriptions  of  leuksemia,  pseudo-leukgemia,  pernicious  anaemia, 
chlorosis,  melansemia,  purpura  simplex,  purpura  rheumatica, 
purpura  hcemorrhagica,  scorbutus,  hsemoglobinuria  and  heemo- 
philia.  What  a  variegated  collection !  How  can  we  consider 
as  belonging  to  one  class  such  affections  as  purpura  simplex  —  a 
but  insignificant  symptom  to  be  met  with  in  a  great  many  differ- 
ent diseases,  and  Werlhoff's  disease,  which,  when  fully  developed, 
presents  all  the  symptoms  of  an  independent  affection,  of  a  disease 
sui  generis^  in  all  probability  of  an  infectious  nature.  On  the 
other  hand,  if  we  place  among  diseases  of  the  blood  purpura 
hsemorrhagica,  in  which  the  primary  affection  of  the  blood  is 
perhaps  probable,  but  has  not  been  proved  as  yet,  then  why  not 
describe  in  the  same  chapter  also  malaria,  in  which  disease  the 
affection  of  the  blood  is  so  apparent,  and  very  probably  of  a 
primary  origin?     If  the  chapter  of  the  diseases  of  the  blood 


—  251  — 

treats  of  leukgemia  and  melana;mia,  in  wiiich  the  alterations  of 
the  blood  are  but  consequent  on  affections  of  the  other  parts  of 
of  the  organism  and  on  other  diseases,  then  why  not  place  there 
also  urpemia,  cholsemia,  etc.  ?  To  treat  thus  of  diseases  of  the 
blood  tends  to  produce  a  vague  idea  about  them  in  the  begin- 
ner's mind  and  puts  them  within  narrow  limits.  A  short  in- 
troduction should  at  least  delineate  fully  the  limits  of  this 
department  of  diseases,  should  distinguish  the  primary  affections 
of  the  blood  from  the  changes  consequent  thereon,  and  should 
keep  it  prominently  before  the  beginner's  mind,  that  it  was  only 
for  the  greater  convenience  of  exposition,  that  either  has  been 
described  in  other  parts  of  the  text-book. 

It  is  evident,  that  placing  chlorosis  in  the  chapter  that  treats 
of  diseases  of  the  blood,  will  assist  but  little  in  explaining  the 
nature  of  this  disease,  especially  if  we  consider  the  modern  ac- 
count of  the  same. 

The  changes  in  the  blood  in  chlorosis  and  their  consequences 
are  evident,  and  to  judge  by  the  present  case,  may  be  very  great : 
but  what  produces  them?  We  do  not  observe  in  oui'  patient 
any  signs  of  an  insufficient  development  of  the  general  circula- 
tory system,  as  the  presence  of  a  narrow  calibre  of  the  vessels, 
etc.,  to  which  Virchow  called  attention  m  cases  of  chlorosis, 
though  they  occur  very  rarely.  The  influence  of  unfavorable 
material  conditions  and  of  disturbances  of  digestion  on  the.  nu- 
trition and  hsematopoiesis  have  to  be  excluded  by  the  very  fact 
of  their  absence  in  the  present  case.  One  thing  is  certain  — 
the  presence  of  a  disease-causing  influence  on  the  nervous  sys- 
tem, namely,  the  depressing  mental  condition.  Influences  of 
such  a  nature  play  an  important  part  in  the  setiology  of  chloro- 
sis\  Some  physicians,  as  for  instance,  the  late  Prof.  Botkin,  in 
his  clinical  lectures  on  chlorosis,  are  even  inclined  to  classify 
chlorosis  with  nervous  affections.  While  I  recognize  fully,  from 
my  own  experience,  the  truth  of  his  observations  as  well  as  of 
those  of  others,  —  observations  of  which  the  present  case  may 
serve  as  an  example,  —  I  still  think  that  the  morbid  influence 
on  the  nervous  system  serves  but  as  the  exciting  cause,  which 
calls  to  the  surface  the  hidden,  but  nevertheless  already  existing 
disease. 


—  252  — 

I  base  my  opinion,  first,  on  the  fact,  that  in  many  cases  chloro- 
sis is  developed  without  any  such  influences  on  the  nervous 
system  ;  secondly,  because  such  influences  on  the  nervous  sys- 
tem cause  chlorosis  only  at  the  age  when  sexual  maturity  is 
in  the  process  of  being  formed,  while  at  any  other  age  no  such 
effect  takes  place;  and  thirdly,  because  even  at  this  age 
they  may  call  out  the  existence  of  the  disease  in  some,  and 
fail  to  do  so  in  others.  It  is  reasonable  to  assume  that  the  im- 
mediate cause  of  the  disease  lies  in  the  process  of  development 
of  sexual  maturity,  and  in  the  condition  and  functions  of  the 
sexual  organs  at  this  period  of  life.  The  signs  of  incomplete 
development  of  the  sexual  sphere  and  the  anomalies  of  men- 
struation, usually  observed  in  chlorosis,  as  well  as  the  remark- 
able facts  which  have  become  known  lately,  all  tend  to  streng- 
then this  assumption  still  further. 

The  well-known  physiologist  Brown-Sequard  promulgated  the 
idea  that  the  glandular  organs  of  our  body  secrete  not  only  ex- 
ternally, but  also  internally,  thus  exerting  an  influence  on  the 
life  of  the  organism.  As  a  particular  confirmation  of  his  idea, 
he  pointed  to  the  inter-relation  between  the  activity  of  the  male 
generative  organs  and  the  general  condition  of  the  organism,  and 
on  this  fact  he  based  the  application,  with  a  therapeutic  aim,  of 
his  well-known  injections.  These  injections  were  at  first  com- 
promised by  being  thoughtlessly  applied,  and  partly  also  through 
invidious  exploitation,  but  at  present  they  are  considered  as 
worthy  of  experimentation  by  serious  investigators.  Similar 
observations  were  at  the  same  time  made  known,  which  tended 
to  prove  the  hitherto  unsuspected  connection  between  the  condi- 
tion of  certain  parts  of  the  body  and  that  of  the  body  as  a 
whole  :  I  refer  to  the  investigations,  which  prove  a  relation  of 
the  thyroid  gland  to  myxoedema,  of  the  suprarenal  bodies  to  Ad- 
dison's disease,  probably  of  the  pituitary  bodies  to  acromegaly, 
of  the  pancreas  to  diabetes.  One  cannot  help  thinking  that 
there  may  be  a  similar  relation  between  some  special  condition 
of  the  sexual  apparatus  during  the  period  of  the  formation  of 
sexual  maturity  and  chlorosis  ;  this  condition  being  such,  that 
only  in  its  presence  may  influences  on  the  nervous  system  cause 
the  development  of  chlorosis,  while  the  other  circumstances,  as 


—  253  — 

failure  in  nutrition  and  blood-formation  from  various  reasons, 
may  favor  this  development.* 

I  must  say  here  a  few  words  on  the  relation  of  chlorosis  to 
hysteria,  in  the  aetiology  of  which  morbid  conditions  of  the 
genital  sphere  also  play  such  an  important  part.  The  combi- 
nation of  chlorosis  and  hysteria  is  seen,  according  to  my  experi- 
ence, not  only  infrequently,  but  rather  rarely.  The  influence  of 
marriage  in  chlorosis  and  hysteria  is  as  follows  :  other  condi- 
ditions  being  equal,  for  example,  with  a  similar  and  withal 
good  constitution,  amidst  similar  and  withal  favorable  con- 
ditions of  life,  hysteria,  even  if  strongly  developed,  often  passes 
away  completely  after  marriage,  or  is  at  least  considerably 
diminished;  while  chlorosis,  if  slight,  becomes  neither  better 
nor  worse  after  marriage  and  requires  treatment ;  but  if  con- 
siderable, it  always  becomes  worse,  so  that  for  chlorotic  girls 
late  marriage  is  more  advisable,  for  the  phenomena  of  chlorosis 
will  then  cease  to  recur  and  will  finally  disappear,  and  sexual 
maturity  as  well  as  that  of  the  whole  organism,  will  be  fully 
established. 

The  prognosis  in  the  present  case  is  favorable,  considering  the 
patient's  fair  constitution,  her  good  conditions  of  life,  and  also 

*  A  later  addition  [from  the  article  of  the  well-known  (by  his  works 
in  the  domain  of  pathology  of  metabolism)  Prof .  Noorden  :  "Altesund 
Neues  liber  Pathologie  nnd  Therapie  der  Chlorose."  — Berliner  Klinische 
Wochenschrift,  iS'os.  9  and  10,  1895].  What  causes  the  diminution  of  hae- 
moglobin in  chlorosis,- — the  increased  disintegration  of  the  blood,  or  the 
weakened  power  of  haematopoiesis  ?  The  bilirubin  of  the  bile  is  formed 
from  the  hsematin.  From  the  bilirubin  there  is  formed  hydrobilirubin  of 
the  feces  and  urobilin,  identical  with  hydrobilirubin ;  this  urobilin  is  ab- 
sorbed by  the  intestines  and  passes  into  the  urine,  of  which  it  forms  the 
principal  coloring  matter.  Thei'efore,  the  general  quantity  of  urobilin  in 
the  urine  and  of  hydrobilirubin  in  the  feces  may  serve  as  an  index  of 
the  disintegration  of  the  haemoglobin.  Not  only  the  pale  urine  and  the 
usually  pale  color  of  the  feces  in  chlorosis,  but  also  direct  measurements 
of  the  quantity  of  urobilin  in  the  urine  and  of  hydi'obilirubin  in  the  feces, 
which  measurements  show  their  diminution  in  this  disease,  —  go  to  prove 
that  the  disintegration  of  the  haemoglobin  is  not  increased  in  chlorosis, 
but  diminished,  and  that  consequently  the  decrease  of  this  body  in 
the  blood  depends  on  the  weakened  power  of  haematopoiesis.  On  the  con- 
trary, in  other  anaemiae, — as  in  the  pernicious,  leukaemic,  febrile,  ma- 
larial, —  where  the  existence  of  an  increased  disintegration  of  the  blood 
is  too  certain,  there  are  constantly  found  greater  quantities  of  urobilin  in 
the  urine  and  of  hydrobilirubin  in  the  feces. 


—  254  — 

in  view  of  the  fact  that  she  has  hardly  been  subjected  to 
any  treatment.  The  prognosis  would  certainly  be  less  favor- 
able, if  her  constitution  and  mode  of  living  were  poor  and  if  we 
had  found  in  her  such  an  extreme  development  of  the  disease 
after  a  considerable  and  frequent  use  of  iron  and  arsenic ;  and 
such  a  thing  does  occur.  Whereas  now,  especially  in  view  of 
the  fact  that  iron  is  well  borne  and  is  evidently  effective,  we 
may  well  hope  to  bring  the  patient  soon  out  of  her  chlorotic 
condition.  It  is  true,  that  this  last  is  liable  to  recur  and  seldom 
yields  to  treatment  instituted  the  first  time  ;  but  with  the  aid 
of  a  good  constitution  and  favorable  conditions  of  life  repeated 
treatment  is  usually  successful  in  preventmg  a  recurrence  and  in 
establishing  the  health  on  a  firm  basis.  Otherwise  the  con- 
dition of  health  is  liable  to  undergo  different  changes,  while  the 
organism  may  acquire  a  predisposition  to  various  diseases,  espe- 
cially to  pulmonary  tuberculosis. 

Treatment  —  First  of  all,  be  sure  to  create  as  favorable  hy- 
gienic conditions  as  possible;  the  principal  therapeutic  means 
are  iron  and  arsenic. 

Before  prescribing  these  drugs  you  must  carefully  investigate 
the  condition  of  the  stomach :  it  is  just  as  erroneous  to  consider 
the  dyspeptic  phenomena  due  to  chlorosis  as  caused  by  a  gas- 
tric catarrh  and  to  hesitate  in  prescribing  iron  and  arsenic,  as  it 
would  be,  on  the  contrary,  to  prescribe  at  once  these  remedies 
without  previously  removing  such  a  catarrh,  in  case  this  last 
condition  were  present.  The  dyspeptic  symptoms,  as  seen  in 
our  patient  with  extreme  chlorosis,  were  trifling,  (vomiting 
after  meals)  and  appeared  only  during  the  course  of  the  chloro- 
sis ;  we  therefore  prescribed  iron  at  once,  and,  to  judge  by  the 
course  of  the  disease,  rightly  so.  Eight  pills  a  day  (the  well- 
known  Blaud's  pills  :  iron  sulphate,  potassium  carbonate  aa, 
tragac.  q.  s.),  four  after  dinner  and  four  after  supper,  each  of 
them  containing  one  and  a  half  grain  of  iron  sulphate,  dimin- 
ished the  phenomena  of  chlorosis,  improved  the  appetite,  while 
the  nausea  after  the  meals  disappeared.  If,  on  the  contrary, 
with  a  moderate  chlorosis  there  were  present  considerable  dys- 
peptic symptoms  which  had  existed  prior  to  the  appearance  of 
the  chlorosis,  then  it  would  have  become  necessary  at  fhst  to 


—  255  — 

remove  them  (most  frequently  by  the  use  of  alkaline  mineral 
water  and  of  bitter  remedies). 

When  shall  we  administer  iron  and  when  arsenic  in  cases  of 
chlorosis  ?  In  proportion  as  the  phenomena  of  chlorosis  are 
more  prominent  and  the  condition  of  nutrition  favorable,  the 
sooner  must  we  give  iron,  and  that  in  large,  frequently  even  in 
very  large  doses,  beginning  with  moderate  ones  and  increasing 
them  gradually ;  the  best  form  is  that  of  pil.  Blaud.  On  the 
contrary,  'if  the  character  of  the  chlorosis  is  less  prominent, 
and  if  the  nutrition  has  suffered  greatl}-,  and  the  more  evidence 
there  is  of  the  case  being  one  of  simple  ansemia,  as  a  result  of 
failure  of  general  nutrition  and  that  of  hsematopoiesis  in  par- 
ticular, —  then  it  is  better  to  administer  in  the  beginning  arse- 
nic, especially  if  the  appetite  be  poor,  thus :  ^.  acidi  arsenicosi 
gr.  j,  extr.  trifolii  q.  s.  ut  f .  1.  a.  pillulse  thirty  or  forty  —  one 
twice  a  day,  after  a  meal ;  and  later  arsenic  combined  with  a  small 
quantity  of  iron,  as :  IJ.  acidi  arsenicosi  gr.  j,  ferri  hydi'ogenio 
reducti  grana  xxx  extr.  trifolii  q.  s.  ut  f.  1.  a.  pil,  xxx,  in 
the  same  dosage.  Still,  there  occur  also  cases  of  pure  chloro- 
sis with  fair  nutrition,  but  of  a  very  obstinate  frequently  re- 
curring nature,  when  the  patients  become  habituated  to  the  use 
of  iron,  this  latter  ceasing  to  exert  any  effect  (so  that  it  is  un- 
able to  prevent  a  recurrence  of  chlorosis)  ;  in  such  cases  the 
administration  of  arsenic — -as  mentioned  above — instead  of 
the  iron,  usually  prevents  the  recurrence  of  the  disease,  after 
which  iron,  in  case  of  another  recurrence,  will  again  act  favorably. 

There  is  no  need  of  interrupting  the  administration  of  arsenic 
itself,  or  in  combination  with  some  iron,  during  the  menstrual 
periods ;  but  we  must  certainly  interrupt  the  administration  of 
large  quantities  of  iron  during  these  periods.  We  frequently 
have  to  stop  the  iron  even  a  few  days  before  the  appearance  of 
menstruation,  otherwise  tliis  latter  will  be  very  profuse,  thus 
weakening  the  patient.  The  attempt  to  continue  the  adminis- 
tration of  iron  up  to  the  very  time  of  the  appearance  of  the 
menstrual  flow  (so  as  to  avoid  the  necessity  for  delaying  the 
treatment),  and  then,  by  using  egortine,  tra.  hydrastis  and  such 
like,  to  diminish  this  flow,  usually  miscarries ;  and  it  is  better 
not  to  hurry  on  with  the  treatment  and  interrupt  it  a  few  days 


—  256  — 

before  the  menstruation  appears.  The  condition  of  tlie  diges- 
tive apparatus  may  also  require  mtermissions  during  the  treat- 
ment by  iron  and  arsenic.  But  in  a  general  way  the  treatment 
is  continued  until  a  complete  and  certain  removal  of  chlorosis 
is  effected. 

I  consider  it  also  necessary  to  remind  you  of  the  fact,  which 
is  unfortunately  liable  to  be  easily  forgotten,  that  while  taking 
arsenic  every  sour  article  of  food  is  to  be  forbidden,  as  meals 
with  vinegar,  lemon,  and  all  sour  or  soured  fruits  and  berries, 
sour  sauces,  as  well  as  horse-radish  and  mustard,  which  are  usual- 
ly prepared  with  vinegar ;  otherwise  a  diarrhoea  may  start  up, 
usually  of  a  painful  and  lasting  nature,  delaying  the  success  of 
the  treatment. 

The  iron  mineral  waters  play  but  a  subordinate  part  in  the 
treatment  of  chlorosis,  principally  because  they  do  not  stand 
transportation  as  well,  for  instance,  as  the  alkaline  waters,  and 
can  be  successfully  used  only  on  the  spot ;  but  the  treatment  of 
chlorosis  and  of  aneemiae  in  general  by  the  aid  of  ferrous  min- 
eral waters  is  not  more  successful  than  the  treatment  by  medi- 
cinal preparations  of  iron,  but  is  in  fact  less  so. 

The  treatment  of  chlorosis  and  of  ansemise  in  general  by  import- 
ed arsenical  and  arseno-ferrous  mineral  waters,  so  widely  adver- 
tised of  late  (Bourboule,  Levico,  Roncegno)  does  not,  from 
my  observations,  present  any  advantage  over  the  treatment  by 
the  above-named  correctly  prepared  medicinal  preparations  of 
arsenic  or  of  arsenic  with  iron. 

The  constipation  is  easily  overcome  in  our  patient  by  watery 
clysters.  These  are  eificient  in  the  majority  of  cases ;  in  ex- 
ceptional cases  we  have  to  administer,  and  that  rarely,  light 
laxatives.  There  seems  to  be  no  reason  for  any  other  symp- 
tomatic treatment  in  the  present  case ;  m  some  cases  we  do 
resort  to  it;  but  the  more  the  physician  refrains  from  such 
treatment,  and  particularly  from  the  use  of  the  various  nervines, 
as,  for  instance,  the  bromides,  and  the  more  he  insists  on  the 
radical  treatment,  the  more  successful  will  he  be  in  establishing 
a  condition  of  sound  health.  I  cannot  help  telling  you  that 
a  predominating  palliative  therapy  in  practice  is  a  sure  sign 
of  a  poor  physician. 


—  257  — 

The  condition  of  the  nervous  system  in  chlorosis  requires 
certainly  the  greatest  attention  on  the  part  of  the  physician,  as 
is  apparent  from  what  we  said  concerning  the  Eetiology  of  the 
disease :  it  is  necessary  to  strengthen  this  system  as  much  as 
possible ;  but  to  effect  this  purpose  we  must  not  direct  our 
efforts  against  individual  nervous  symptoms,  but  we  must  act 
on  the  whole  system.  It  is  true  that  both  iron,  by  improving 
the  condition  of  the  blood,  and  arsenic  directly,  improve  the 
state  of  the  nervous  system  as  a  whole ;  but  the  application  of 
hydi'otherapeutic  and  of  balneotherapeutic  means  in  general  is 
also  very  beneficial  in  this  connection.  If  the  patients  are  not 
predisposed  to  chills,  then  bathing  in  the  river,  or,  better  still, 
in  the  sea,  is  the  simplest  means.  Unfortunately,  in  cases  of 
considerable  chlorosis,  patients  are  usually  chilly  and  become 
weak  after  bathing ;  for  such  cases  we  must  order  baths  at  the 
temperature  of  27°  it.  (92.8°  F.")  and  lower,  so  that  the  patients 
while  m  the  bath,  would  feel  refreshed,  but  not  chilled,  and 
after  the  bath  would  become  quickly  warmed  and  feel  vigorous. 
,Such  baths  are  best  prepared  with  table-salt  and  soda.  Warm 
baths  (29°  R,  and  over;  97.2°  F?)  tend  to  weaken  such  pa- 
tients. 

As  our  patient  is  not  habituated  to  bathing  in  the  river 
it  will  be  more  suitable  to  advise  her  to  take  the  above-named 
baths  for  the  coming  summer  season. 

The  patient  was  treated  under  the  supervision  of  one  of  our 
clinical  assistants :  the  result  of  the  treatment  was  entirely 
successful. 


EIGHTEENTH  CASE. 


LECTURE  OF  MARCH  5,  1893. 

The  patient,  a  young  girl  nineteen  years  old,  entered  our 
clinic  March  2d,  complaining  of  dyspnoea,  palpitation  and 
dizziness  on  moving  around,  and  of  general  weakness. 

Mode  of  living  and  anamnesis.  —  Up  to  within  two  years  ago 
the  patient  lived  in  a  small  country  town  in  a  healthy  locality 
and  in  favorable  circumstances ;  but  since  then  she  has  been 
living  constantly,  summer  and  winter,  in  Moscow.  Her  resi- 
dence is  fair.  She  bathes  outside,  but  during  the  last  j-ear 
bathing  tended  to  weaken  her  and  cause  dizziness.  She  neither 
smokes,  nor  drinks  coffee  or  wine ;  drinks  some  four  glasses 
of  tea  daily,  sweetened  and  with  lemon.  Has  three  meals  a 
daj^  but  they  frequently  consist  of  lunches  onlj^,  as  bologna, 
cheese,  etc.  She  is  a  student  of  midwifery  and  attends  her 
lectures  from  nine  o'clock  m  the  morning  to  three  o'clock  in 
the  afternoon ;  her  evenmgs  are  spent  m  sewing  and  reading ; 
she  has  sufficient  time  for  sleep ;  goes  out  for  about  an  hour 
and  a  half  in  the  fresh  air,  but  during  her  service  as  mterne  in 
the  lying-in  hospital  (six  days  every  month)  she  is  entirely  con- 
fined to  the  house.  Durmg  the  last  year  she  is  becoming  very 
much  fatigued  from  her  studies. 

In  her  childhood  patient  passed  through  attacks  of  mea- 
sles, scarlatina  and  mflammation  of  the  lymphatic  glands  on 
the  right  cheek,  which  suppurated  and  left  a  scar.  Since  then 
and  up  to  the  time  she  moved  to  Moscow,  she  enjoyed  good  health, 
with  the  exception  of  an  attack  of  malaria,  which  was  of  short 
duration  and  yielded  to  qumine.  During  the  first  winter 
that  the  patient  spent  at  Moscow,  she  began  to  feel  weak- 
ness, dyspnoea  and  palpitation ;  the  appetite  became  impaired, 
there  appeared  dyspepsia  and  an  inclination  to  costiveness, 
258 


—  259  — 

ana  menstruation  became  verj  irregular  ;  later  on,  in  May  of  last 
year,  during  laborious  preparations  for  the  examinations,  there 
appeared  considerable  hEemoptysis.  During  the  summer  the 
patient  remained  at  Moscow,  and  the  condition  of  weakness, 
the  dyspnoea,  palpitation  and  dizzmess  kept  increasing.  In 
October  patient,  havmg  caught  cold,  began  to  cough,  and  at  this 
time  she  also  had  haemoptysis  for  two  days,  felt  some  pain  in  the 
left  side  of  the  chest,  and  was  feverish.  In  the  course  of  a 
month  all  these  phenomena  disappeared  but  the  weakness, 
dyspncea,  palpitation  and  dizziness  became  aggravated.  In 
January  patient  was  takmg,  during  two  weeks,  tra.  nervina 
Best,  without  any  appreciable  results. 

Status.  —  Patient  is  of  a  weakly  constitution,  of  tall  stature, 
but  with  an  insufficiently  developed  somewhat  flat  chest,  and 
pale.  The  appetite  is  poor.  Eating  is  accompanied  by  belch- 
ing, pyrosis,  nausea  and  by  a  sensation  of  heavmess  m  the 
stomach.  She  is  usually  costive,  but  there  occur  at  times 
loose  stools  ;  thus,  during  the  last  twenty-four  hours  she  had 
.  three  loose  stools,  accompanied  by  pains  in  the  abdomen.  The 
urine  contains  neither  albumen  nor  sugar,  its  specific  gravity 
is  1021.  The  liver  and  spleen  present  nothing  abnormal. 
The  menstruation,  which,  previous  to  her  coming  to  Moscow, 
was  regular  and  painless,  has  become  very  irregular  since, 
appears  only  once  every  two  or  three  months,  and  is  accom- 
panied by  abdominal  pains ;  she  menstruated  last  time  six 
weeks  ago.  The  heart  is  not  enlarged,  its  tones  are  clear,  there 
are  no  murmurs,  pulse  is  very  variable,  between  60  and  84,  and 
weak.  Movement  causes  palpitation  and  dyspnoea.  The  number 
of  the  red-blood  corpuscles  is  50  per  cent.,  that  of  the  heemoglo- 
biii  35  per  cent,  of  the  normal.  Leucocytosis  and  poikilocytosis 
absent.  There  is  a  slight  enlargement  of  the  thyroid  gland. 
Patient  does  not  cough,  but  has  at  times  pams  in  the  left  side 
of  the  chest,  especially  after  she  has  been  sitting  for  a  long 
time  in  a  stooping  position.  Careful  objective  uivestigation  of 
the  lungs  elicits  nothing  abnormal.  Patient  grew  thin  ;  she  is 
slightly  feverish  —  36.4.°/iJ.  (97.5°  F.)  in  the  mornmg,  37.4  R. 
(99.5°  i^.)  in  the  evening.  Sleeps  poorly;  is  dizzy;  has  at 
times  attacks  of  migraine  with  vomitmg.    After  sitting  for  a  long 


—  260  — 

time,  experiences  heaviness  in  the  head  and  pain  in  the  loins. 
There  is  considerable  general  debility. 

Diagnosis.  —  The  simultaneous  appearance,  about  a  year  and 
a  half  ago,  of  general  weakness,  dyspnoea,  palpitation,  dizziness, 
of  a  sensation  of  noise  in  the  head,  and  of  the  irregularity  of 
menstruation,  and  the  occurrence  of  changes  in  the  blood,  and  the 
enlargement  of  the  thyroid  gland,  all  point  to  chlorosis ;  but 
we  have  here  evidently  something  more  to  deal  with  than 
chlorosis  only.  The  hsemoptysis  during  last  May  and  especially 
the  above-described  disease  of  last  autumn  point  to  tuberculosis 
of  the  lungs.  The  absence  of  pronounced  objective  signs  in 
the 'chest,  as  well  as  of  cough  and  expectoration,  do  not  certain- 
ly speak  agamst  it.  Not  to  speak  of  the  literature  of  the 
subject,  even  a  limited  personal  experience  is  sufficient  to 
prove  the  fact,  that  such  rapidly  passing,  incidental  illnesses, 
as  that  from  which  our  patient  suffered  last  autumn,  are  of 
frequent  occurrence  during  the  mcipient  stage  of  pulmonary 
tuberculosis ;  they  pass  away  apparently,  but  usually  precede 
the  development  of  the  real  disease  and  serve  therefore  as  a 
true  indication  of  the  presence  of  this  last.  It  would  be  an 
unpardonable  mistake  to  hesitate  in  such  cases  in  taking  the 
necessary  measures  against  pulmonary  tuberculosis  and  to  wait 
for  local  symptoms  —  beginning  with  the  cough  and  objective 
data  to  the  finding  of  bacilli  inclusive.  For  the  rest,  our  pa- 
tient presents  also  some  local  symptoms,  as  pains  in  the  left 
half  of  the  chest,  and  general  indications,  as  slight  fever,  the 
most  probable  cause  of  which  m  the  present  case  is  tuberculosis 
of  the  lungs. 

A  question  may  arise  as  to  whether  the  group  of  symptoms 
presented  by  our  patient,  so  peculiar  to  chlorosis  and  appearing 
at  the  beginnuig,  did  not  depend  also  on  an  incipient  tuberculo- 
sis of  the  lungs,  i.  e.,  whether  our  patient  had  before  and  has 
now  chlorosis,  or  only  pulmonary  tuberculosis.  Against  the 
last  supposition  speaks  experience  which  proves  that,  although  at 
the  beginning  of  pulmonary  tuberculosis  emaciation,  pallor  and 
weakness  are  apt  to  occur,  such  a  simultaneous  collection  of  symp- 
toms peculiar  to  chlorosis,  as  observed  in  our  patient,  does  not 
take  place ;  besides,  we  note  considerable  alterations  in  the  blood 


—  261  — 

and  an  enlargement  of  the  thyroid  gland.  We  must,  however, 
take  into  account  the  fact,  that  the  above-mentioned  signs  of  an- 
£emia  are  due  not  to  chlorosis  alone,  but  depend  certainly  on  fail- 
ure in  nutrition  and  haematopoiesis  amidst  the  unfavorable  con- 
ditions under  which  our  patient  lived  while  in  Moscow,  and,  later 
on,  also  because  of  the  incipient  tuberculosis  pulmonum ;  so  that 
we  may  call  the  disease  chloranaemia,  which,  having  attacked 
a  weak  constitution,  created  a  predisposition  to  pulmonary 
tuberculosis. 

Prognosis.  —  It  will  be  more  convenient  for  us  to  discuss  the 
prognosis  of  chronic  tuberculosis  of  the  lungs  after  we  will  have 
analyzed  a  few  cases  of  this  disease ;  as  far  as  the  present  case 
is  concerned,  I  can  only  say  that  it  is  curable. 

Treatment.  —  We  will  first  of  all  advise  our  patient  to  give 
up  her  studies  and  to  return  to  the  former  favorable  conditions 
of  life,  until  she  is  well  again. 

As  regards  treatment,  we  must  certainly  first  of  all  remove 
the  dyspeptic  symptoms.  The  patient  is  already  taking  Ems 
water  —  one-half  glassful  twice  a  day,  warmed,  one  hour  before 
a  meal  —  and  bitter  drops  (extr.  fluidi  condurango  guttas  xxx 
and  trae.  nucis  vomicae  guttas  v,  twice  a  day  after  a  meal),  and 
for  overcoming  constipation  she  resorts  to  the  use  of  watery 
clysters.  In  view  of  the  diarrhoea  of  the  last  few  days  we  will 
prescribe  ten  grains  of  bismuth  once  or  twice  a  day  pro  re  nata 

What  shall  we  give  her  after  the  dyspeptic  symptoms  will 
have  been  removed?  Shall  we  treat  the  chlorosis  or  the  tuber- 
culosis ?  We  must  certainly  treat  the  tuberculosis,  —  first, 
because  of  the  greater  danger  it  presents,  and  secondly,  because 
the  principal  remedy  for  chlorosis,  namely  iron,  especially  in 
large  doses,  is  clearly  contraindicated  in  the  present  case,  as  it 
may  give  rise  to  haemoptysis,  to  which  the  patient  is  so  much  pre- 
disposed, and  which  may  favor  the  further  development  of  the 
pulmonary  trouble.  Perhaps  later  on,  after  this  last  will  have 
been  completely  and  securely  interrupted,  we  may  be  able,  if 
necessary,  to  prescribe  iron,  certainly  not  in  large  doses,  and 
with  due  care.  Concerning  arsenic,  it  is,  firstly,  contraindicated 
partly  by  the  long-standing  dyspepsia  and  the  frequently  occur- 
ring attacks  of  diarrhoea ;  and  secondly,  although  it  is  used  in  the 


—  262  — 

treatment  of  tuberculosis,  it  is  much  inferior  in  its  effects  in 
this  disease  to  creosote  and  guaiacol.  Of  all  the  apothecary 
drugs  at  our  disposal,  these  last  two,  in  the  present  condition  of 
our  knowledge,  are  the  most  successful  ones  in  the  treatment 
of  tuberculosis.  I  shall  discuss  these  and  the  treatment  of  tu- 
berculosis in  general  when  we  come  to  analyze  some  cases  of 
this  disease ;  but  I  will  only  state  here,  that  not  only  in  incipi- 
ent tuberculosis,  but  also  in  cases  presenting  a  failure  in  nutri- 
tion or  anaemia,  or  slight  chlorosis  with  only  a  predisposition 
to  tuberculosis  (on  account  of  heredity,  or  of  a  poorly  developed 
chest),  I  have  frequently  witnessed  much  more  benefit  from 
the  use  of  these  remedies,  than  from  the  employment  of  arsenic 
alone  or  in  combination  with  iron. 

In  vicAv  of  all  this  we  will  prescribe  for  our  patient,  after  the 
dyspeptic  symptoms  will  have  been  removed,  guaiacol  carbon- 
ate, it  being  borne  by  the  stomach  readily,  in  five-grain  doses, 
after  each  meal,  at  other  times  in  a  half-glass  of  milk ;  we  will 
constantly  increase  the  number  of  the  doses,  and  administer  the 
drug  for  a  long  time,  but  with  interruptions,  till  we  will  have 
secured  a  complete  and  lasting  cessation  of  the  pulmonary 
trouble. 

FROM^,THE  ILECTURE  OF  MARCH   16,   1893. 

Until  March  12th  we  continued  the  above-outlined  treat- 
ment of  the  digestive  troubles  ;  and  we  were  enabled  since  then 
to  leave  off  this  treatment  and  to  prescribe  guaiacol  carbonate, 
in  five-grain  doses,  the  first  two  days  one  dose  a  day.  and  later 
two  doses  daily.  The  condition  of  the  patient  at  present  is 
as  follows :  the  appetite  is  better ;  there  is  no  dyspepsia,  stools 
regular ;  during  the  period  of  menstruation  that  occurred 
recently  after  a  prolonged  absence  of  the  same,  there  was  an 
evening  rise  in  the  temperature  (as  is  frequently  to  be  seen  in 
tuberculous  women  during  their  menstruation)  up  to  37.6°  R. 
(99.7°  #.),  and  now  it  is  36.6°  R.  (97.5°)  ;  the  dizziness,  heavi- 
ness in  the  head  and  the  general  weakness  have  diminished 
considerably.  Patient  leaves  our  clinic  to-morrow  and  will 
continue  the  treatment  with  guaiacol  in  constantly  increasing 
doses,  guided  by  the  results  of  the  treatment  and  the  condition 
of  the  stomach. 


THORACIC  AND   INFECTIOUS 
DISEASES. 


NINETEENTH  CASE. 


LECTURE   OF  JANUARY   29,    1893. 

The  patient,  a  merchant's  clerk,  thirty-seven  years  of  age,  en- 
tered our  clinic  yesterday,  complaining  of  severe  pain  in  the 
left  side,  of  dyspnoea,  cough  and  general  debility. 

Mode  of  living  and  anamnesis.  —  Patient  has  lived  for  the 
last  twenty-two  years  constantly  in  Moscow ;  formerly  lived  in 
the  country.  His  lodging-rooms  are  good,  with  a  warm  water- 
closet  ;  but  he  spends  the  day  m  a  cold  store.  He  takes  a  hot 
bath  once  a  week;  does  not  bathe  during  the  summer;  drmks 
as  many  as  fifteen  glasses  of  hot  tea  per  day ;  is  subject  to 
sweating.  Has  been  drmking  whiskey,  half  a  bottle  daily, 
for  a  long  time;  somewhat  less  for  the  last  two  months.  Does 
not  smoke.  Has  a  good  board.  Is  married  and  has  a  few  chil- 
dren.    Never  had  syphilis. 

Four  years  ago,  after  a  blow  over  the  nape  of  the  neck,  on 
which  dropped  a  bale  of  goods,  there  appeared  on  the  injured 
part  a  small  swelling,  which  soon  disappeared,  accompanied  by 
pain,  which  was  also  relieved  in  the  course  of  time,  but  which, 
on  his  catching  cold,  reappears  even  now  (periostitis  of  the  occi- 
pital bone).  Outside  of  this  and  of  some  slight  colds,  which, 
as  he  claims,  were  relieved  by  hot  baths,  patient  has  no  recollec- 
tion of  any  other  diseases.  The  present  trouble  began  six  days 
ago :  patient  was  severely  chilled  by  a  draught  and  in  the  even- 
ing felt  pain  in  the  head  and  weakness,  but  this  notwith- 
standing he  went  out  to  take  a  hot  bath ;  on  his  return  he 
began  to  shiver  and  felt  a  pain  in  the  left  side.  On  the  next 
day  he  grew  worse  still,  the  pain  was  aggravated,  there  ap- 
peared a  cough,  patient  was  compelled  to  take  to  his  bed,  and 

263 


—  264  — 

remained  in  a  condition  which  was  growing  worse  all  the  time, 
till  his  admission  to  the  clinic  ;  for  the  last  five  days  he  has  been 
taking  quinine  powders,  one  in  the  morning  and  one  in  the 
evening.  Yesterday  he  was  given  in  the  clmic  a  watery  in- 
jection, the  painful  side  was  rubbed  with  butter  and  chloroform 
and  wrapped  in  cotton  and  flannel,  and  internally  we  began 
to  administer  the  mixture  of  Hoffman  and  Valeriana  drops, 
twenty-five  at  a  dose,  and  also  some  wine ;  besides,  he  was 
given  in  the  evening  one-fourth  grain  of  codeine. 

Status.  —  Patient  is  spare  and  of  weakly  constitution  ;  his 
chest  is  flat  and  narrow.  Until  the  advent  of  the  disease  his 
appetite  was  good,  he  sufi^ered  from  no  dyspeptic  symptoms, 
and  had  regular  movements  of  the  bowels.  At  present  he  has 
almost  no  appetite  at  all ;  a  meal,  even  if  light,  causes  difficulty 
in  breathing ;  he  had  no  movements  of  the  bowels  for  four  days 
previous  to  his  admission  to  the  clinic,  but  yesterday  a  clyster 
brought  on  a  sufiicient  evacuation.  The  urine  flows  freely,  is 
red,  and  contains  neither  albumen  nor  sugar.  No  abdominal 
pains.  The  regions  of  the  liver,  spleen  and  kidneys  present 
nothing  abnormal.  There  is  dyspnoea  of  the  same  character  as 
yesterday,  thirty -six  respirations  per  minute,  much  more  frequent 
on  moving  around;  the  pains  in  the  side  are  somewhat  quieter, 
and  so  is  the  cough ;  there  is  very  little  expectoration  (twice 
during  twenty-four  hours).  Objective  investigation  on  the  right 
side  elicits  nothing  abnormal ;  on  the  left  side  posteriorly,  from 
the  middle  of  the  scapula  downward,  there  is  dullness,  as 
well  as  over  the  lateral  surface  ;  the  vocal  fremitus  is  very  much 
weakened ;  on  auscultation,  all  over  the  left  half  of  the  chest, 
the  respiratory  murmur  is  weaker  than  on  the  right  ride  and 
non-vesicular,  but  of  an  indefinite  character ;  the  respiratory 
murmur  is  especially  weak  at  the  area  of  the  dull  sound ;  besides 
this,  posteriorly,  over  the  surface  of  the  dull-sound  area  there 
are  heard  along  a  narrow  zone  some  rales  of  an  atelectatic  char- 
acter, while  anteriorly,  almost  on  the  same  level,  there  can  be 
perceived  a  pleuritic  rubbing  sound.  The  intercostal  spaces  on 
the  left  side  of  the  chest  are  sensitive  to  pressure.  The  heart 
is  neither  displaced  nor  enlarged,  its  tones  are  clear ;  the  pulse 
is  110,  regular,  of  fair  volume  (patient  gets  through  the  day 


—  265  — 

four  tablespoonfuls  of  wine  and  seventy-five  drops)  ;  it  was 
weak  yesterday.  The  temperature  yesterday  morning,  38.1°i^. 
(100.5°^.)'  ill  the  evening  39.6° J?.  (103.3°i^.),  this  morning 
again  S8.1°E.  (100.5°i^.).  Patient  slept  somewhat  better 
than  he  did  while  at  home,  but  still  poorly,  and  was  slightly  de- 
lirious. The  whole  head  aches,  but  especially  the  injured  spot. 
There  is  slight  dizziness  on  getting  up ;  the  weakness  as  for- 
merly. 

Diagnosis.  —  We  have  apparently  to  do  here  with  an  acute  tho- 
racic disease,  which  causes  the  febrile  condition  and,  through 
this,  some  disturbance  in  the  organs  of  digestion  and  in  the  ner- 
vous system.  The  disease  itself  is  evidently  not  located  in  the 
thoracic  wall,  which,  outside  of  the  sensitiveness  of  the  intercostal 
spaces,  presents  a  healthy  condition,  but  within  the  chest,  in  the 
pleura  or  iu  the  lung.  What  is  it  then  —  pleuritis  or  pneumonia  ? 
All  the  symptoms  speak  against  pneumonia  and  for  pleuritis  : 
the  severe  pains,  the  weakened  respiratory  murmur  in  connection 
with  a  considerable  area  of  a  dull  sound  (if  there  were  pneu- 
monia in  the  case  we  would  have,  according  to  the  period  of  the 
disease,  either  pronounced  bronchial  respiration,  or,  in  the  begin- 
ning, crepitation,  and,  at  the  end,  subcrepitation),  the  pleuritic 
friction  sound,  weakened  vocal  fremitus  and  a  dry  cough;  the 
expectoration  is  triflmg  in  quantity  and  does  not  have  the  pneu- 
monic character.  The  considerable  difference  between  the 
morning  and  evening  temperature — 38.1°it.  (100.5°  i^.)  and 
39.6°  R.  (103.2°  i^.) — is  not  usually  peculiar  to  pneumonia. 
Thus  the  case  is  one  of  pleuritis,  and  to  judge  by  the  consid- 
erable area  and  intensity  of  the  dull  sound,  by  the  weakened 
respiratory  murmur  and  vocal  fremitus,  and  partly  also  by  the 
degree  of  the  dyspnoea,  there  must  be  a  considerable  effusion. 

With  this  the  diagnosis  is,  however,  not  at  an  end.  Pleuritis 
may  be  of  variable  origin :  it  maybe  due  only  to  a  cold,  and  al- 
though this  causative  agency  is  disputed  by  many,  my  observations 
lead  me  to  think  that  its  existence  can  hardly  be  denied ;  it  is  fre- 
quently due  to  tuberculosis,  to  pyogenic  microbes  (the  strepto- 
cocci and  the  staphylococci),  to  acute  articular  rheumatism,  to  in- 
flammatory conditions  of  the  kidneys,  sometimes  to  syphilis,  ac- 
tinomycosis and  other  diseases.     What  is  the  origin  of  the  pleu- 


—  266  — 

ritis  in  the  present  case  ?  To  attempt  to  prove  that  the  disease 
in  the  present  case  is  not  due  to  acute  articular  rheumatism,  be- 
cause this  last  is  absent,  or  to  nephritis,  on  account  of  the  ab- 
sence of  this  disease,  or  to  syphilis,  because  of  its  absence,  etc., 
as  would  be  attempted  by  a  clinician  who  zealously  believes  in 
"  the  usefulness  of  exercises  in  differential  diagnostication" 
(and  there  are  such),  would  be  but  a  profitless  task,  which, 
moreover,  lowers  the  utility  of  a  method  really  useful  in  certain 
cases  and  to  a  certain  extent.  From  the  collection  of  data  re- 
ferring to  the  case  before  us  it  becomes  apparent,  first,  that  cold 
has  played  undoubtedly  an  important  part  in  the  aetiology  of 
the  pleuritis,  and  secondly,  that  notwithstanding  the  absence 
of  indisputable  symptoms  of  jDulmonary  tuberculosis,  it  would 
be  rather  rash  on  our  part  to  conclude,  in  view  of  the  patient's 
weak  constitution  and  poor  nutrition,  as  well  as  because  of  the 
long-continued  abuse  of  whiskey  so  ruinous  to  health,  and  with- 
out further  observation  and  examination  of  the  sputum,  that 
the  pleuritis  was  entirely  due  to  cold,  and  that  the  patient  was 
free  from  tuberculosis. 

What  is  the  character  of  the  effusion  in  our  patient  ?  In 
cases  of  pleuritis  caused  by  cold  only,  and  also  in  pleuritis  of 
this  nature  in  tuberculous  persons,  the  effusion  is  usually,  at 
least  at  the  beginning,  of  a  serous  character.  To  decide  the 
question  of  the  nature  of  the  pleuritic  exudate  we  have  to  resort  to 
a  trial  aspiration ;  but  this  procedure  has  to  be  adopted  only 
when  the  disease  yields  to  no  other  treatment,  whereas  our  treat- 
ment is  only  just  begun. 

Prognosis.  —  Pleuritis  caused  by  a  cold,  as  well  as  pleuritis  with 
pulmonary  tuberculosis,  may  eventuate  in  a  complete  return  to 
health ;  but  the  condition  of  our  patient  must  nevertheless  be 
recognized  as  serious,  namely,  as  such,  which,  without  present- 
ing any  immediate  danger,  may  lead  to  it  in  the  future,  as  we 
learn  from  the  pathology  of  the  disease. 

Treatment.  — ■  Before  discussing  the  treatment  of  our  patient, 
I  must  make  a  few  general  remarks  concerning  my  treatment 
of  pleurisy,  as  it  differs  from  the  treatment  recommended  by  the 
most  widely  read  text-books  on  internal  pathology  and  thera- 
peutics. 


—  267  — 

Thus  we  find  in  Eichhorst's  Handbuch  d.  speciell.  Pathol,  u. 
Therapie  (  fourth  edition,  vol.  I,  p.  590)  : 

"  In  a  recent  and  uncomplicated  serous  pleuritis  we  must,  in 
the  beginning,  quietly  wait  "  (Bei  einer  frischen,  nicht  complicir- 
ten  serosen  Pleuritis,  warte  man  zuniichst  ruhig  zu).  Later  on, 
if  during  the  second  and  third  week  the  disease  presents  no 
changes,  we  are  to  employ  internal  remedies  to  aid  in  the  absorp- 
tion of  the  exudate  ;  but  if  by  the  fourth  or  fifth  week  we  were 
unable  to  achieve  any  success,  and  the  effusion  is  considerable 
or  is  even  increasing  in  quantity,  then  we  must  resort  to  thora- 
centesis to  effect  its  removal.  Of  internal  drugs  to  aid  absorp- 
tion, Eichhorst  recommends  iodine  (with  due  care  also  exter- 
nally, over  the  painful  side  of  the  chest),  diuretics,  seldom 
laxatives,  rather  strong  diaphoretics  (subcutaneous  injections 
of  pilocarpine  hydrochlorate  and  per  os  salycilic  acid  and  so- 
dium salycilate),  while  for  debilitated  and  anaemic  patients, 
nutritious  food  and  strengthening  measures. 

But  I,  on  the  contrary,  consider  it  erroneous  to  "  wait  quiet- 
ly "  until  the  second  or  third  week,  limiting  one-self  to  hygiene 
and  palliative  measures.  My  observations  teach  me  that  the 
sooner  we  succeed  in  breakuig  up  the  acute  stage  of  the  pleu- 
risy, the  more  favorable  will  be  the  further  course  of  the  dis- 
ease, and  the  sooner  will  occur  absorption  of  the  effusion  and 
the  possibility  of  aiding  it  by  therapeutic  measures.  Even  in 
those  cases,  as  for  instance,  in  acute  pleurisy  in  syphilitic  or 
tuberculous  patients,  in  which,  later  on,  the  cure  of  the  pleurisy 
and  the  return  to  health  in  general  will  be  effected  by  other 
treatment,  having  a  particular,  special  relation  to  the  principal 
disease,  as  iodide  and  mercury  in  syphilis,  creosote  and  its  pre- 
parations in  tuberculosis,  —  even  in  such  cases  the  acute  stage 
of  pleurisy,  if  pronounced  clearly,  requires  a  preliminary  treat- 
ment of  a  particular  character  for  itself. 

The  principal  symptoms  which  characterize  the  acute  stage 
of  pleurisy,  and  which  form  an  indication  for  such  a  treatment 
are  fever  and  pain  in  the  chest ;  with  these  there  are,  of  course, 
dyspnoea  and  a  dry  cough,  which  are  the  more  embarrassing 
the  more  prominent  the  first  two  symptoms  :  until  these  last 
are  removed,  or  at  least  consider-ably  relieved,  we  cannot  hope 
for  the  absorption  of  the  effusion  to  take  place. 


—  268  — 

For  the  treatment  of  the  acute  stage  of  pleuritis,  for  the  re- 
moval of  the  above-named  symptoms,  I  resort  to  the  following : 
To  relieve  the  pains  I  employ  blood-letting;*  certainly  in 
patients  who  are  not  anaemic,  but  in  those  with  good  nutrition 
and  strength,  and  consequently,  as  we  can  see  by  the  aetiology 
of  the  disease,  in  cases  of  rather  unfrequent  occurrence.  Next 
to  blood-lettmg,  or,  if  this  be  contra-indicated,  then  at  once, 
keep  the  painful  side  warm,  as  in  the  present  case,  or  in  case  of 
necessity,  give  hypodermic  injections  of  morphine,  and  internally 
codeine,  Dover's  powder,  or  again  morphine  to  quiet  the  cough 
that  tends  to  aggravate  the  pains  m  the  chest. 

The  best  remedy  against  the  fever  I  consider  to  be  sodium 
salycilate  ;  at  the  same  time  I  administer  stimulants  (to  guard 
against  collapse),  which  are,  moreover,  generally  indicated  m 
pleuritis.  It  is  here,  in  the  acute  stage  of  pleuritis,  that  the 
great  usefulness  of  this  drug  becomes  apparent,  as  it  causes  a 
fall  in  the  temperature  and  at  the  same  time  induces  a  pro- 
nounced relief  of  the  pains,  of  the  dyspnoea  and  cough.  I  ad- 
minister the  drug  in  ten-grain  doses,  and  during  twenty-four 
hours  I  begin  with  thirty  or  forty  grains  and  increase  the 
quantity  as  required ;  m  moderately  severe  cases,  as  the  present 
one,  three  or  four  days  of  such  treatment  are  sufficient  to  bring 
about  the  desired  result. 

I  will  not  stop  to  discuss  here  the  various  drugs,  the  effect  of 
which  is  similar  to  that  of  the  salycilate  of  soda  (as  antipyrin, 
antifebrine,  phenacetine),  to  which,  in  pleurisy,  I  prefer  this 
last,  but  will  say  a  few  words  on  the  use  of  calomel  and  qui- 
nine in  this  disease. 

I  administer  calomel  in  pleurisy  only  in  those  very  rare  cases, 
in  which  this  disease  is  complicated  by  certain  morbid  condi- 
tions in  the  abdomen,  which  form  an  indication  for  calomel 
(of  this  I  spoke  before)  ;  consequently  calomel  is  given  not 
against  the  pleuritis  itself,  but  with  a  view  of  meeting  such 
indications. 

Quinme  does  not  have  even  a  shadow  of  the  effect  produced 
by  the  salycilate  of  soda  in  pleurisy.  While  speaking  of  the 
comparative  effects  of  quinine  and  sodium  salycilate  in  pleurisy, 

*  Vide  article  on  ''blood-letting." 


—  269  — 

I  will  mark  down  the  following  difference  between  them,  as 
observed  in  my  experience :  quinine  acts  well  in  febrile  affec- 
tion of  the  respiratory  tract  (of  the  nose,  pharynx,  larynx,  tra- 
chea, bronchi}  of  a  catarrhal  nature  caused  by  colds,  better  than 
the  sodium  salycilate  ;  this  last  acts  well  in  febrile  diseases  of  the 
organs  of  locomotion  due  to  colds,  and  especially  of  the  muscles, 
aponeuroses  and  articulations  (in  the  healthy  organism,  as  well 
also  as  in  the  gouty,  syphiKtic,  and  in  the  one  generally  dis- 
eased), in  which  quinine  exerts  almost  no  effect  whatever. 

I  will  take  up  now  the  further  treatment  of  pleuritis.  Hav- 
ing removed  the  above-mentioned  acute  symptoms  so  as  to 
further  absorption  of  the  effusion,  I  take  particular  care  to 
establish  a  regular  functional  activit}^  of  all  parts  of  the  organism, 
a  good  nutrition  and  a  favorable  condition  of  the  nervous  sys- 
tem ;  as  what  concerns  therapy,  I  apply  flying  blisters,  so  as 
not  to  keep  up  the  irritation  later  on,  over  the  pamful  half  of 
the  chest.  With  the  exceiDtion  of  in  syphilitics,  I  do  not  use 
iodine  internally  m  pleuritis,  as  I  did  not  obtain  any  benefit 
from  it,  but  on  the  contrary  harm,  the  general  condition  be- 
coming worse  ;  iodine  externally  fails  to  produce  any  marked 
effect,  while  it  annoys  the  patient  and  hmders  the  application 
of  the  blisters.  Except  when  necessary  laxatives  are  certainly 
harmful,  as  they  tend  to  weaken  the  patient.  The  diuretics  can 
not  be  relied  upon  to  a  great  extent.  The  strong  diaphoretics 
are  very  risky,  and  may  be  used  only  for  exceptional  cases,  and 
even  then  they  can  hardly  be  preferred  to  the  operative  method 
for  removing  the  effusion. 

As  what  concerns  this  last  procedure  I  resort  to  it,  first, 
when  the  exudation,  if  considerable,  is  not  undergoing  any  ab- 
sorption for  a  long  time  ;  but  still  I  do  not  hasten,  and  do  not 
limit  myself  to  the  four  or  five  weeks'  period  recommended  by 
the  text-books ;  I  had  occasion  to  observe  that  a  considerable 
effusion  which  had  existed  longer  than  this  period,  and  which 
in  the  opinion  of  some  physicians  required  operative  abstraction, 
but  which  was  not  thus  removed  at  the  advice  of  other  physi- 
cians, imderwent  absorption  with  the  improvement  in  the  gen- 
eral condition  of  the  patient,  thanks  to  better  hygienic  condi- 
tions and  to  a  more  careful  surveillance  over  the  regularitias  of 


—   270   — 

.functional  activity  and  over  the  condition  of  nutrition  and  of 
the  nervous  system  of  the  patient ;  secondly,  in  case  of  rapid 
mcrease  in  the  effusion,  and  of  the  danger  to  life  accompany- 
mg  this  mcrease  because  of  the  pressure  on  and  displacement 
of  the  neighboring  organs  ;  thirdly,  in  cases  of  purulent  and  pu- 
trid effusion,  which  tends  to  keep  up  the  exhausting  fever. 

I  turn  now  to  the  treatment  of  our  patient.  Blood-letting  is 
contra-indicated  by  his  debilitated  constitution  and  nutrition, 
and  we  therefore  had  to  limit  ourselves  to  keeping  warm  the 
painful  side  of  the  chest  and  to  quieting  the  cough.  As  the 
temperatm^e  w-as  high  last  night,  d9.6°E.  (103.3°^.),  we  will 
prescribe  to-day  sodium  salycilate,  begimiing  with  four  ten- 
grain  doses  per  day,  each  dose  in  one-fourth  glass  of  warm  Ems 
water.  The  stimulants,  which  were  indicated  even  yesterday  by 
the  weakness  of  his  pulse,  it  is  the  more  necessary  to  continue 
giving  to-day,  in  view  of  the  fact  that  we  are  administering  so- 
dium salycilate,  as  far  as  necessary  and  in  a  larger  dose. 

As  what  concerns  hygienic  conditions,  the  prmcipal  ones  in 
pleuritis  are  rest  and  warmth.  The  ''  ambulance  "  treatment  of 
pleuritis,  even  if  this  last  be  inconsiderable,  will  lead,  particularl}^ 
in  the  cold  season  of  the  year,  to  a  more  dangerous  aggravation 
of  the  disease. 


FROM  THE  LECTURE  OF  FEBRUARY  3,    1893. 

The  course  of  the  disease.  —  January  29th  we  gave  him  forty 
grains  of  the  salycilate,  the  evening  temperature  was  38.4° i^. 
(101.1°-F.)  ;  the  night  of  January  30th  was  spent  somewhat 
better.  The  30th  he  was  given  fifty  grains  of  the  salt,  the 
evening  temperature  was  37.5°i^.  (99.o°i^.)  ;  had  a  very  good 
night  the  31st ;  January  31st  and  February  1st  he  was  given 
forty  grains  of  the  drug  each  day,  and  the  temperature  fell 
then  for  good,  while  the  condition  of  the  patient  improved  at 
once.  Yesterday,  February  2d,  he  w^as  not  given  any  of  the 
salt  at  all. 

Status.  —  He  feels  very  well;  has  an  appetite.  Had  regular 
stools  for  the  last  two  days  without  clysters.  The  urine  in- 
creased in  quantity,  and  is  not  red.     The  pain  on  the  left  side 


—  271  — 

of  the  chest  is  much  relieved  and  he  can  breathe  more  freely ; 
the  number  of  respirations  is  twenty-four  per  minute,  instead  of 
thirty-six  as  formerly.  He  coughs  much  less.  The  quantity 
of  expectoration  has  not  dimmished,  and  it  contains  tuberculous 
bacilli.  The  pleuritic  friction  murmur  disappeared.  The  area 
of  dullness  has  dimmished.  In  the  area  of  dullness,,  as  well  as 
all  over  the  left  side  of  the  chest  in  general,  the  respiratory 
murmur,  which  was  formerly  weak  and  of  an  indefinite  quality, 
became  much  clearer,  while  in  the  region  of  the  apex  of  the 
left  lung,  in  front,  under  the  clavicle,  as  well  as  behind,  there 
appeared  moist  rales.  The  pulse  is  80  and  of  fair  volume. 
Last  evening's  temperature,  S6.6°B.  (97.9°i^.).  This  morning, 
36.5°^.  (97.6°^.).  His  sleep  is  good.  There  is  neither  headache 
nor  dizziness  on  getting  up.     He  is  gathering  more  strength. 

The  presence  of  the  tubercle  bacilli  in  the  sputum  and  of 
the  rales  in  the  superior  apex  of  the  left  lung,  which  could 
not  be  heard  when  the  patient  was  unable  to  fully  expand  the 
left  lung,  as  he  could  not  breathe  sufficiently  deep,  and  which 
became  noticeable  now  when  breathing  became  free,  speak 
for  tuberculosis  of  the  lungs. 

The  beneficial  effect  of  the  sodium  salycilate  is  but  too 
evident  in  the  present  case.  After  the  first  few  days  of  the 
patient's  sojourn  in  the  clinic  under  entirely  normal  circum- 
stances, which  were  more  favorable  than  duiing  the  first  six 
days  of  the  disease  before  his  admission  to  the  clinic,  and  with 
the  aid  of  the  necessary  symptomatic  treatment,  the  improve- 
ment in  the  patient's  condition  was  but  triflmg ;  but  from  the  very 
first  day  that  we  began  the  use  of  the  salycilate  of  soda  the 
temperature  began  to  decline  rapidly,  and  in  four  days  a 
complete  breaking  up  of  the  disease  took  place:  the  tempera- 
ture fell  finally  to  the  normal  and  the  local  symptoms  de- 
creased very  markedly. 

At  present,  while  keeping  continually  the  left  half  of  the 
chest  warm,  we  will  apply  a  blister,  the  size  of  the  palm  of  the 
hand,  under  the  left  scapula,  and  for  internal  use  we  will  give 
him  creosote,  beginning  with  five  drops  three  times  a  day,  and 
increasing  the  dose  gradually. 


272  — 


FROM   THE   LECTURE   OF   FEBRUARY   17,    1893. 

The  course  of  the  disease.  —  Febuary  3d  we  applied  the  first 
blister  under  the  left  scapula ;  the  9th,  the  second  one  on  the 
lateral  surface  of  the  left  side  of  the  chest.  Since  February 
14th,  patient  is  treated  by  inhalations  of  compressed  air.  He 
takes  creosote  in  eight-drop  doses,  three  times  a  day. 

Status.  —  The  appetite  is  good,  there  is  no  dyspepsia,  the 
stools  are  regular,  the  urine  normal.  At  times  patient  experi- 
ences a  trifling  pain  in  the  left  side.  The  breathing  is  free. 
There  is  almost  no  cough,  and  there  is  but  very  little  expectora- 
tion, which  appears  at  times,  and  is  absent  at  others.  Objec- 
tive examination  shows  that  there  is  only  under  the  scapulse  a 
slight  difference  in  the  percussion  sound  and  that  the  respira- 
tory murmur  is  but  slightly  weaker  on  the  left  side.  In  the 
region  of  the  apex  of  the  left  lung  there  are  sometimes  heard 
a  few  rales,  at  other  times  they  are  absent.  The  temperature 
is  normal,  the  sleep  quiet ;  he  gathers  strength. 

Treatment.  —  The  blisters  are  not  necessary  any  more.  The 
creosote  must  certainly  be  continued.  The  benefit  derived 
from  inhalations  of  compressed  air  during  the  period  of  the 
absorption  of  the  pleuritic  exudate,  is  but  too  well  known. 
The  patient  asserts,  that  after  the  inhalation  of  compressed 
air  breathing  became  easier  and  the  sensation  felt  by  him 
heretofore,  outside  of  the  pain,  of  tightness  in  the  left  side, 
was  relieved  (as  the  patient  expresses  it,  "  the  side  was 
loosened  ").  Our  patient,  however,  presents  some  contra-indi- 
cation  to  this  treatment,  in  view  of  the  tuberculous  nest  in 
the  left  lung,  and  it  was  only  because  of  the  inconsiderable 
size  of  this  nest  that  I  ordered,  three  days  ago,  previous  to  the 
absorption  of  the  exudate,  the  inhalation  of  compressed  air. 
In  the  presence  of  more  or  less  considerable  tuberculous  nests 
such  inhalations  are  not  only  not  beneficial,  but,  on  the  contrary, 
rather  harmful,  probably  because  they  assist  in  aspiration  of 
tuberculous  expectoration  by  the  healthy  portions  of  the  lungs. 
In  our  apparatus  (Waldenburg's)  for  inhalation  of  compressed 
air,  the  air  is  conducted,  as  you  see,  from  outside  through  a  win- 


—  :273  — 

dow-frame  and  is  warmed  in  a  special  apparatus.  The  air  for  our 
patient,  conducted  from  the  outside  and  warmed  before  being  ad- 
mitted to  a  Waldenburg  apparatus,  is  passed  through  a  Wolff 
jar  containmg  eucalyptus  oil. 

The  patient,  considerably  strengthened,  left  the  clinic  Febru- 
ary 22d.  He  was  mstructed  as  to  the  necessary  regimen,  and 
was  advised  to  continue  the  creosote  treatment. 


TWENTIETH   AND   TWENTY-FIRST  CASES. 


LECTURES  OF  APRIL  %  13  AND   14,    J893, 

Patient,  a  sergeant-major  of  the  reserve  army,  age  37,  en- 
tered our  clinic,  March  8,  189S,  complaining  of  dyspnoea, 
cough  with  expectoration,  pain  in  the  left  side  and  general 
weakness. 

Mode  of  living  and  ariamnesis:  —  Patient  resides  in  a  damp, 
marshy,,  woody  locality.  His  rooms  are  very  small,  damp  and 
cold  ;  the  water-closet  is  cold.  For  the  last  three  years  he 
has  almost  never  taken  a  hot  bath,  although  he  washes  himself 
at  times  at  home  ;  does  not  smoke  or  drink  whiskej'  (he  drank 
and  smoked  much  formerly),  drinks  only  a  little  warm  tea. 

His  food  is  that  of  an  ordinarj^  workingman.  He  is  single, 
never  had  syphilis.  Our  patient  is  a  clerk  in  a  country  house, 
is  much  occupied,  does  not  sleep  sufhciently,  is  often  fatigued. 
and  subjected  to  colds,  as  he  is  compelled  to  talk  much  and 
loudly  out-of-doors  in  every  season  of  the  year. 

Patient  comes  from  a  healthy  family.  Since  his  nineteenth, 
year,  he  was  addicted  to  the  abuse  of  whiskey.  During  his 
twentieth  year  he  passed  through  an  attack  of  malaria,  which, 
lasted  nine  months.  On  his  twenty -second  year  he  entered  the 
military  service,  in  which  he  spent  five  years,  during  which  time 
he  did  not  drink  any  liquor,  and  enjoyed  excellent  health, 
liecoming  a  reserve,  he  began  to  drink  again,  and  seven  years 
ago,  while  employed  m  rafting,  he  began  to  cough,  at  first  only 
slightly,  but  later  on  much  more.  Two  and  one-half  years 
later,  in  the  autumn  of  1888,  he  suffered  for  the  first  time 
from  haemoptysis,  which  lasted  for  about  one  month  (about  one 
half-glassful  of  blood  daily)  and  weakened  the  patient  consid- 
erably:  he  grew  thin,  and  began  to  complain  of  dyspncpa.     Dur- 


—  -275  ^ 

mg  the  autumn  of  1889  there  occurred  another  attack  of 
hsemoptysis,  which  lasted  a  week ;  patient  at  the  same  time  be- 
gan to  grow  feverish  and  to  feel  a  pain  in  the  left  side* 
Then,  at  the  advice  of  his  physician,  he  gave  up  whiskey 
drinking  and  smoking,  and  subjected  himself  to  treatment.  Of 
the  drugs  employed  for  treatment  he  remembers  that  creosote 
was  of  the  greatest  benefit  of  all,  and  he  had  been  takmg  it 
during  the  winter  of  1891-1892,  up  to  forty  drops  a  day,  in 
milk;  as  a  result  of  this  treatment  he  gathered  considerable 
strength,  and  became  somewhat  stout,  while  the  fever,  cough 
and  the  pain  in  the  side  diminished.  Last  January  all  the  mor- 
bid symptoms  reappeared  again,  as  the  result  of  a  cold.  Pa- 
tient has  been  taking  since  cod-liver  oil  (three  tablespoonfuls 
a  day),  at  times  powders  of  codeine,  and  applied  blisters,  but 
there  was  no  improvement. 

During  the  month  that  the  patient  resided  in  the  clinic,  the 
treatment  was  as  follows ;  as  he  was  costive,  he  was  given,  when 
necessary,  watery  clysters  ;  during  the  mornmg  cough,  which 
was  most  embarrassing,  as  the  expectoration  was  then  brought 
up  with  great  difficulty,  patient  sipped  about  one  glass  of  a  mix- 
ture of  Obersalzbrunnen  water  and  warm  milk  ;  this  assisted  ma- 
terially in  loosening  the  secretion  ;  at  bed-time,  in  case  the 
cough  prevented  sleep,  patient  was  given  one-quarter  grain  of 
codeme  ;  the  left  side  of  the  chest  was  kept  warm  ;  as  the  pulse 
was  somewhat  weak,  he  was  given  four  tablespoonfuls  of  wme 
dail}^ 

From  the  very  first  day  of  the  patient's  sojourn  m  the  clinic, 
he  has  been  taking  creosote,  commencing  with  five  drops  up  to 
thirty  drops  a  day.  Besides  this,  patient  took,  March  29th 
and^SOth,  some  ipecacuanha  (mfusi  rad.  ipecac,  e  gr.  vj  fvj, 
altogether  twice  this  quantity)  which  was  indicated  by  the  diffi- 
cult expectoration  with  the  aggravated  djspncea  and  rales,  and 
also  with  the  rise  in  temperature,  up  to  38.8'' it;  (101. 9°i^.), 
while  before  this  the  temperature  was  below  38°i?.  (100.5°i^.)  ; 
after  having  taken  the  ipecac,  patient  expectorated  very  freely, 
the  dj^spnoea  was  relieved,  the  rales  diminished  and  the  temper- 
ature reached  its  previous  height. 

Status.  —  Patient  is  of  average  constitution.     The  appetite, 


—  276  — 

which  was  poor  on  admission,  is  good  no\A'.  Tliere  was  no  dys- 
pepsia before,  nor  is  there  any  now.  The  stools  are  regular 
at  present.  The  urine  flows  freely,  contains  neither  sugar  nor 
albumen,  was  reddish  on  admission,  but  is  of  a  normal  color 
now.  The  pams  in  the  left  side  of  the  chest,  not  severe  before, 
are  trifling  now.  The  dyspnoea  and  cough  are  much  better  at 
present  than  they  were  when  the  patient  was  admitted  to  the 
clinic. 

There  are  no  pains  in  the  abdomen,  nor  does  objective  exam- 
mation  discover  anythmg  abnormal  in  it.  At  the  time  of 
admission  he  had  a  muco-purulent  expectoration,  of  about  one- 
half-glassful  per  day,  mixed  with  blood ;  at  present  it  is  just 
half  of  what  it  was  formerly.  Repeated  examinations  of  the 
expectoration  always  showed  the  presence  of  tubercle  bacilli. 
On  percussion  the  sound  over  the  left  side  anteriorly  from  the 
clavicle  to  the  fourth  rib,  as  well  as  posteriorly  from  above 
down  to  the  middle  of  the  scapula,  is  duller  than  from  the  mid- 
dle of  the  scapula  downwards  and  on  the  right  side,  where  the 
percussion  sound  is  normal ;  on  auscultating  the  left  side,  over 
the  area  of  dullness,  we  hear  bronchial  breathing  and  abundant 
moist  rales ;  on  the  right  side,  under  the  clavicle,  there  are  also 
at  times  heard  a  few  rales ;  at  the  other  parts  of  both  the  left 
and  the  right  sides  of  the  chest  we  hear  the  normal  respiratory 
murmur,  either  vesicular  or  indefinite,  in  accordance  with  the 
depth  of  the  respiratory  movements.  The  heart  is  neither  en- 
larged nor  displaced,  its  tones  are  clear,  the  pulse  was  at  the 
begmning  100  and  somewhat  weak,  but  is  now  88  and  of  fair 
volume.  When  admitted,  his  evening  temperature  was  about 
^S°R.  (100.5°^.),  and  the  morning  below  S1°E.  (98.6°i^.)  ;  now 
in  the  evenmg  it  is  37.6°i?.  (99.7°-F.)  or  SLb^E.  (99.5.°i^.)  and 
in  the  morning  below  Sl°Il.  (98.6°^.).  Patient  is  very  thin  : 
his  weight  when  admitted  was  147  pounds,  it  is  now  119.  His 
sleep  is  good  now  ;  it  was  prevented  formerly  by  cough  and 
dyspnoea.  There  is  no  headache.  He  has  become  markedly 
stronger  than  he  was  on  admission. 

Diagnosis.  —  It  is  evident,  that  we  have  here  before  us  a 
pure  case  of  chronic  tuberculosis  of  the  lungs,  which  causes  all 
the  morbid  symptoms  observed  in  our  patient,  the  local  as  well 


—  277  — 

as  the  general  ones,  as  fever,  emaciation,  and  weakness  ;  the  other 
organs  seem  to  be  unaffected.  The  lungs  may  become  affected 
by  tuberculosis,  first,  from  the  neighboring  organs ;  such  cases 
are  of  comparatively  unfrequent  occurrence  generally,  and  are 
particularly  rarely  seen  in  the  clinic  for  internal  diseases ;  they 
are  more  frequently  met  with,  as  tuberculosis  of  the  vertebrae. 
in  surgieial  and  peediatric  clinics ;  besides,  they  pla}^  but  a  sec- 
ondary part  m  the  principal  affection  ;  secondly,  through  the 
blood,  when  there  is  a  general  infection  of  this  last  ;  these  are 
also,  comparatively  speaking,  rare  cases  of  miliar}-  tuberculosis  of 
the  lungs ;  and,  thirdly,  most  frequently,  through  the  respira- 
tory passages,  when  the  apices  of  the  lungs  become  first  affected* 
(either  both  at  once  or  at  the  beginnmg  one,  and  then  the 
other),  and  later  when  the  affection  spreads  by  contiguity  or 
through  aspiration  of  the  tuberculous  expectoration  b}-  the  hith- 
erto healthy  portions  of  the  Imigs  ;  these  are  the  cases,  which  are 
known  in  pathological  anatomy  as  broncho-pneumonia  tuberculosa 
chronica,  and  which  are  called  in  common  parlance  consump- 
tion of  the  lungs,  and  in  the  clmics,  hospitals  and  by  physicians 
chronic  tuberculosis  of  the  lungs.  The  present  case  belongs 
evidently  to  this  last  class  :  the  tubercular  affection  of  the  Imigs, 
in  view  of  the  other  unaffected  organs,  is  present  beyond  doubt 
and  to  a  considerable  extent :  both  the  superior  lobe  of  the  left 
lung  and  the  apex  of  the  right  one  are  affected :  the  anamnesis 
gives  sufficient  proofs  of  its  chronic  course,  ^^'hile  the  absence 

*  This  is,  however,  a  disputed  question.  Thus  Volland  (Zeitschrift 
fiir  clinische  Medicin,  1893),  denying  that  the  presence  of  the  tubercle 
bacilli  in  the  air  was  ever  proved,  assumes,  that  infection  by  tuberculosis 
takes  place  in  infancy,  when  the  children  are  not  on  the  arms  of  the 
mother  or  nurse,  but  unable  as  yet  to  walk,  they  crawl  about,  rub  their 
hands  over  the  floor,  on  which  there  may  be  some  tuberculous  expecto- 
ration, and  then  over  their  faces,  and  thus  infect  themselves  through 
accidental  lesions  of  continuity,  so  frequent  around  the  mouth  and  nose. 
The  infection  by  tuberculous  and  other  microbes  gives  at  first  rise  tu 
eruptions  ("scrofulous"),  and  later  to  an  affection  of  the  lymphatic 
glands ;  then  in  the  presence  of  a  predisposition  to  tuberculosis,  be  it 
hereditary  or  acquired,  the  disease  will  sooner  or  later  spread  from  the 
primary  focus  in  a  general  way,  but  most  frequently  along  the  lymphatic 
vessels  and  the  glands  of  the  neck  andpleui-a,  the  apices  of  the  lungs,  etc. 
Kesting  on  these  grounds  and  on  some  other  data,  which  he  cites, 
Volland  insists  upon  prophylactic  measures  consistent  with  these  last. 


—  -278  — 

of  the  exhaustive  fever  (namelv,  chills,  constant  and  consider- 
able rises  and  falls  of  the  temperature  as  well  as  abundant 
sweating)  shows,  that  the  period  of  consumption,  phthisis 
proper,  has  not  as  yet  arrived. 

The  prognosis  will  be  more  conveniently  discussed,  when  we 
speak  of  the  prognosis  in  chronic  pulmonary  tuberculosis  in 
general ;  while  the  treatment,  in  view  of  the  success  attained  by 
it,  will  of  course  remain  the  same. 

Patient  left  the  clinic  by  the  end  of  April,  considerably 
strengthened  and  markedly  grown,  his  weight  being  one  hun- 
dred and  fifty-six  pounds,  as  against  one  hundred  and  forty- 
seven  on  admission  ;  he  had  no  fever,  no  pains  in  the  side, 
almost  no  dyspnoea,  and  a  slight  cough  with  about  one-fourth 
of  a  glass  of  expectorated  matter  per  day;  he  was  advised  to 
continue  the  creosote  in  constantly  increased  doses. 


This  patient  is  a  woman,  forty-six  years  old,  who  entered  the 
clinic  April  2,  1893,  complaining  of  dyspnoea,  cough,  and 
general  weakness. 

Mode  of  living  and  anamnesis.  —  Patient  has  been  livmg  for  a 
long  time,  during  both  winter  and  summer,  in  jMoscow.  Her 
residence  was  always  a  poor  one,  of  late  she  lived  in  the  base- 
ment of  a  stone  building,  which  was  cold  and  damp,  the  water- 
closet  cold.  Takes  a  hot  bath  every  week.  For  the  last  half- 
year  patient  gave  up  smokmg  and  whiske}'  drinkmg,  but  used 
to  smoke  before,  and  drank  a  wineglassful  of  whiskey  with  both 
dinner  and  supper ;  drinks  but  little  tea ;  her  board  is  that  of 
a  working-woman.  Her  occupation  —  in  the  line  of  house- 
keeping — ■  is  burdensome,  so  that  patient  frequently  does  not 
sleep  enough  and  is  overworked.  Goes  but  rarely  out-of-doors. 
Has  been  married  for  twenty-six  years,  has  had  eleven  deliveries, 
all  normal,  last  time  eight  years  ago  ;  has  five  children  living ; 
presents  no  indications  of  syphilis. 

Patient  comes  from  a  healthy  family,  and  enjoyed  during  her 
childhood  fair  health.  When  fifteen  years  old  she  passed 
through  an  attack  of  typhoid  fever.      Later  on  she  caught  fre- 


—  279   — 

qiient  colds  and  coughed  at  times.  Twelve  years  ago  she  had 
a  slight  attack  of  acute  articular  rheumatism.  Eight  years  ago 
a  pleurisy  on  the  right  side,  after  which  the  cough  became  con- 
stant, more  severe  in  the  winter  than  in  the  summer,  accom- 
panied at  times  by  fever  and  pain  in  the  right  side.  Last 
January  (1893)  the  patient's  condition  became  considerably 
aggravated,  as  a  result  of  vexatious  troubles  and  of  a  cold :  the 
cough  became  very  severe ;  there  appeared  considerable  dysp- 
noea and  a  feverish  condition,  the  patient  grew  thin  and  lost 
strength,  and  her  voice  became  very  hoarse  and  weak.  As  far 
as  treatment  is  concerned,  patient  resorted  lately,  as  well  as  be- 
fore, to  the  use  of  Dover's  powders,  and  at  rare  times  to  ipeca- 
cuanha ;  she  never  took  any  creosote. 

Durmg  her  residence  in  the  clinic  patient  was  given,  when 
necessary,  a  watery  clyster,  and  every  morning  a  glassful  of 
Obersalzbrunnen  water  with  milk,  to  be  sipped  during  the 
cough ;  at  bed-time  a  powder  containing  one-fourth  grain  of 
codeine,  and  durmg  the  day  twentj^  drops  three  times  a  day 
of  the  mixture  of  liq.  anod.  Hofmanni  and  liq.  ammoniianisati* 
aa.  Besides  this,  patient  took,  on  her  admission,  ^vj  of  mfu- 
sion  of  ipecac  (e  gr.  vj),  then  terpine  hydrate,  five  grains 
per  dose,  at  the  beginning  twice,  and  later  on  three  times 
per  day,  and  for  the  laryngeal  catarrh  she  inhaled  atomized 
silesian  water. 

Status  to-day,  April  9th.  —  The  aj)petite,  which  was  poor  on 
her  admission,  is  better  now.  There  is  no  dyspepsia.  The 
former  costiveness  is  somewhat  relieved.  The  urine,  which 
was  reddish  formerly,  is  almost  of  normal  color,  without  al- 
bumen or  sugar.  The  abdomen  in  general  and  the  regions  of  the 
liver,  spleen  and  kidneys  present  nothing  abnormal.  Menstruation 
is  unfrequent  —  once  in  two  or  more  months  (last  time  one 
month  ago)  —  quite  abundant,  but  painless  ;  no  leucorrhoea. 

When  admitted,  she  had  considerable  dyspnoea,  pains  all 
over  the  chest,  and  especially  in  the  right  side,  severe  cough, 
some  expectoration,  mostly  of  a  muco-purulent  character,  partly 
foamy   and  tinged    with    blood,  more  than    a  glassful  during 

*  Liq.  ammon.  anisatus  is  a  mixture  consisting  of  liq.  amnion.  19.5  per 
cent.,  anise  oil  2.4  per  cent,  and  alcohol  (90  per  cent.),  78  per  cent. 


—  280  -- 

twenty-four  hours ;  the  expectoration  shows,  at  times,  the  pres- 
ence of  the  tubercle  bacilli;  percussion  elicits  nothing  abnormal 
anywhere  in  the  chest,  on  auscultation  we  hear  everywhere  a  great 
number  of  rales,  dry  and  moist,  and  over  the  apex  of  the  right 
lung,  in  front  and  in  the  back,  some  slight  bronchial  breathing 
(the  percussion  sound  is  not  altered  in  those  places).  At  pres- 
ent the  dyspnoea,  cough  and  expectoration,  as  well  as  the  rales, 
are  much  less  prominent,  the  pain  m  the  chest  is  greatly  re- 
lieved. The  voice,  which  was  very  hoarse  and  weak  on  her  ad- 
mission (laryngoscopic  examination  showed  the  presence  of  a 
laryngeal  catarrh),  is  clearer  and  stronger  now.  The  heart  is 
neither  displaced  nor  enlarged,  its  tones  are  clear,  the  pulse,  100 
and  weak  on  admission,  is  now  84  and  stronger. 

The  highest  temperature  the  patient  reached  during  her  stay  in 
the  clinic,  took  place  the  day  before  yesterday  :  namely,  37.8°i^. 
(100°^.)  in  the  mornmg,  38.2°i?.  (100.7°^.)  in  the  evenmg ; 
this  morning  the  temperature  was  37.6° i^.  (99.6°i<'.),  last  even- 
ing, 37.8°i?.  (100° J^.)  Her  sleep,  which  was  formerly  pre- 
vented by  the  cough,  is  at  present  much  more  quiet.  At  rare  in- 
tervals patient  suffers  from  migraine,  and,  when  fatigued,  from 
dizziness.     She  is  much  stronger  than  she  was  when  admitted. 

Diagnosis. — The  presence  of  tubercle  bacilli  m  the  expectora- 
tion is  an  undisputable  proof  that  the  patient  has  pulmonary 
tuberculosis,  while  the  other  data,  concernmg  both  her  present 
condition  and  her  past  history,  as  the  bronchial  breathing  and 
the  rales  in  the  region  of  the  apex  of  the  right  lung,  the  pains 
m  the  right  side  of  the  chest,  and  the  chronic  course  of  the  disease, 
strengthen  this  supposition  and  point  to  that  form  of  tuber- 
culosis from  which  our  previous  patient  also  suffers,  namely, 
chronic  tuberculous  broncho-pneumonia.  But  the  two  cases 
differ  from  each  other  hy  the  great  variance  in  the  local,  as  well 
as  in  the  general  symptoms,  and  by  the  course  of  the  disease. 

Let  us  take  the  local  data  first.  Our  male  patient  presents 
pronounced  symptoms  of  a  complete  affection  of  the  whole 
upper  half  of  the  left  lung,  as  evidenced  by  dulhiess  in  this 
region,  by  bronchial  breathing  and  abundant  rales,  while  the 
other  parts  of  the  chest,  with  the  exception  of  the  few  rales 
heard  at  times  on  the  right  side,  under  the  very  clavicle,  pre- 


—  281  — 

sent  nothing  morbid,  as  evidenced  by  a  normal  percussion 
sound,  and  a  normal  respiratory  murmur ;  in  our  female  patient 
the  percussion  sound  is  everywhere  normal  and  there  are  rales 
in  abundance  all  over  the  chest.  The  male  patient  has  evident- 
ly a  complete  tubercular  affection  of  a  considerable  extent  of 
the  upper  portion  of  the  left  lung,  while  the  remaining  parts  of 
the  lungs,  outside  of  the  right  apex,  are  unaffected  either  by 
tuberculosis,  or  by  a  simple  bronchial  catarrh ;  in  the  female  pa- 
tient, if  we  consider  the  bronchial  breathmg  and  the  rales  in  the 
region  of  the  right  apex  as  a  sign  indicating  the  presence  of  a 
tuberculous  nest  (which  is  shown  loj  the  presence  of  bacilli  in 
the  sputum)  in  this  region,  what  then  must  be  the  condition  of 
the  remaining  parts  of  the  bronchi  and  of  the  lungs  ?  We  may 
suppose  in  this  connection  two  morbid  conditions :  first,  an  or- 
dinary bronchial  catarrh,  secondly,  a  chronic  tubercular  broncho- 
pneumonia diffused  all  over  the  lungs,  not,  however,  as  a  com- 
plete process,  but  in  small  islands  surrounded  by  pulmonary 
tissue  containing  air,  and  which  do  not  therefore  cause  any  dull- 
ness nor  bronchial  breathing ;  such  cases  are  usually  observed 
during  the  further  course  of  the  disease  (as  their  development 
requires  some  time),  at  its  very  termmation,  at  the  period  of  phthi- 
sis, when  the  exhaustive  fever  and  the  extreme  emaciation  of  the 
organism  foretell  the  approach  of  the  fatal  issue ;  but  even  at 
this  time,  when  the  aspect  of  the  patient  itself  is  a  clear  indica- 
tion of  the  diagnosis  and  of  the  prognosis,  even  then  the  physi- 
cian can  only  hear  rales  on  auscultation,  but  can  nowhere  obtain 
a  sure  alteration  in  the  precussion  sound,  nor  generally  any 
positively  certain  symptoms  of  a  compact  thickening  of  the  pul- 
monary tissue. 

Before  we  decide  as  to  which  of  the  two  diseases  our  female 
patient  suffers  from,  whether  it  is  a  chronic,  at  times  exacer- 
bated, bronchial  catarrh,  or  a  chronic  tubercular  broncho-pneu- 
monia diffused  all  over  the  lungs  in  its  last  stage,  let  us  compare 
the  course  of  the  disease  and  the  general  condition  of  both 
patients.  The  male  patient  is  thirty-seven  years  old,  he  comes 
from  a  healthy  family,  lived  under  unfavorable  conditions  of  life 
and  abused  alcoholic  drinks,  but  for  the  last  three  years  he  has 
not  been  drinking  or  smoking,  and  has  subjected  himself  to 


—  282  — 

quite  a  radical  treatment ;  but  this  notwithstanding,  having 
been  ill  only  seven  years,  he  loses  his  health  steadily. 

The  female  patient  is  forty-six  years  old,  she  comes  from  a 
healthy  family,  has  been  surrounded  by  similar  poor  circum- 
stances, has  also  been  a  drinker  (although  a  rather  moderate 
one,  as  she  asserts)  and  a  smoker,  has  had  eleven  children,  has 
been  ailing  for  eight  years,  had  never  subjected  herself  to  radi- 
cal treatment,  and  still  her  health  is  not  failing  as  rapidly  as  it 
does  in  the  male  patient ;  on  the  contrary  it  is  rather  in  a  con- 
dition of  a  tolerable  statu  quo,  worse  in  the  winter  as  regards 
the  cough  and  the  dyspnoea,  and  better  during  the  summer,  but 
it  is  not  accompanied  by  such  periods  of  fever  and  such  a  con- 
tinuous emaciation,  as  we  find  in  our  male  patient.  Let  me 
add,  that  while  in  the  clinic,  the  woman  improves  more  rapidly 
than  the  man  (thus,  the  fever,  generally  trifling  and  without 
having  the  slightest  symptom  of  an  "  exhaustive"  nature,  dis- 
appears itself  without  any  resort  to  antifebrile  remedies) ;  still 
we  did  not  as  yet  give  her  any  creosote,  while  the  man  began  to 
take  it  from  the  very  day  of  his  admission  to  the  clinic. 

We  are  justified  then  in  concluding  from  the  above  state- 
ments, that  our  female  patient  has  a  moderately  developed 
broncho-pneumonia  tuberculosa  chronica  and  a  diffuse  chronic 
bronchial  catarrh,  but  not  a  broncho-pneumonia  tuberculosa 
chronica  disseminated  over  the  whole  lungs,  in  its  last  stage. 
This  conclusion  is  strengthened  also  by  the  fact,  that  the 
muco-purulent  expectoration,  peculiar  to  bronchial  catarrh,  as 
observed  in  our  patient,  contained  only  at  rare  intervals  the 
tubercle  bacilli,  whereas  the  sputum  of  phthisical  patients 
contains  them  usually  in  abundance. 

Prognosis.  —  The  chronic  bronchial  catarrh,  as  well  as  the 
broncho-pneumonia  tuberculosa  chronica  as  developed  in  our 
patient,  are  both  yielding  to  treatment,  which  is  the  more  en- 
couraging, as  the  patient  up  to  this  time  was  treated  solely  in 
a  palliative  way. 

Treatment.  —  To  explain  why  we  gave  the  patient  Obersalz- 
brunnen  mixed  with  milk  in  the  morning,  codeine  at  bedtime, 
the  mixture  of  liq.  anod.  Hofmanni  and  liq.  ammonii  anis., 
as  a  cardiac  stimulant  and  as  a  means  to  promote  expectoration, 


—  283  — 

during  the  day,  and  why  we  gave  on  her  admission  ipecac ;  to 
explain  all  these  after  what  was  said  in  connection  with  the  treat- 
ment of  the  foregoing  case,  appears  to  me  superfluous  ;  as  re- 
gards terpine  hydrate,  I  will  say,  that  on  a  par  with  the  alka- 
line mineral  waters,  it  forms  the  best  remedy,  of  those  for 
internal  use,  for  the  treatment  of  chronic  bronchial  catarrh ;  as 
soon  as  the  exacerbation  of  the  disease,  which  compelled  the 
patient  to  come  to  the  clinic,  has  quieted  down,  we  will  begin 
the  treatment  by  creosote. 

(The  female  patient  continued  the  above  outlined  treatment 
up  to  the  time  she  left  the  clinic,  April  23d ;  when  she  left 
her  condition  was  as  follows  :  appetite  normal,  stool  regu- 
lar, the  dyspnoea,  cough,  expectoration  and  rales  have  dimin- 
ished greatly,  there  are  no  pains  in  the  right  side,  nor  is  there 
any  fever ;  the  sleep  is  sound,  the  patient  gathered  strength 
and  became  somewhat  stout;  she  weighs  133  pounds  as  against 
129  she  weighed  when  admitted.  She  was  prescribed  creosote 
treatment.) 

GENERAL  REMARKS  CONCERNING  THE  DIAGNOSIS 
OF  CHRONIC  TUBERCULOSIS  OF  THE  LUNGS. 

We  have  analyzed  four  cases  of  chronic  pulmonary  tubercu- 
losis. 

First,  episodic,  transient  affections  of  the  lungs  by  tuberculo- 
sis, which  precede  the  development  of  the  permanent  disease 
in  a  person  predisposed  to  tuberculosis  because  of  a  weakly 
constitution  and  the  presence  of  chloraneemia. 

Second,  a  small  tuberculous  focus  in  the  apex  of  the  left 
lung,  complicated  by  pleurisy  of  the  left  side. 

Third,  a  complete  considerable  affection  of  the  left  lung 
and  an  incipient  affection  of  the  right  one,  without  any  compli- 
cations. 

Fourth,  a  moderate  affection  of  the  lungs  (apparently,  to  a 
greater  extent,  of  the  right  one),  complicated  by  a  chronic 
bronchial  catarrh,  which  at  times  becomes  greatly  exacerbated. 

The  cases  of  pulmonary  tuberculosis,  which  are  to  be  seen 
at  this  time  in  the    clinic,  present,    outside  of   the    two    last 


—  284  — 

discussed  cases,  the  same  condition  as  tlie  third  case  ana- 
lyzed by  us,  namely,  chronic  tuberculous  broncho-pneumonia  in 
various  stages  of  development,  but  without  any  complications 
and  in  general  without  any  pronounced  peculiarities,  and  there 
appears  therefore  no  reason  for  taking  them  up  for  discussion. 
There  is  one  case  of  chronic  pulmonary  tuberculosis  in  its  last 
stage,  in  that  of  phthisis  declarata,  but  the  patient  is  so  exhaust- 
ed, and  the  final  issue  is  so  near  at  hand,  that  it  is  impossible  to 
transfer  him  from  his  small  ward  into  the  auditorium  for  dem- 
onstration before  the  class. 

However,  the  four  cases  discussed  by  us  represent  practically 
the  most  important  clinical  forms  of  chronic  pulmonary  tubercu- 
losis—  those  which  are  particularly  accessible  to  treatment,  and 
in  which  treatment  is  of  the  greatest  benefit.  The  complications 
which  occurred  with  them  —  chloransemia,  pleurisy  and  bron- 
chial catarrh  —  are  also  very  important,  as  they  are  observed 
particularly  often. 

It  is  true,  that  the  multiplicity  of  forms  of  chronic  tuberculo- 
sis of  the  lungs,  which  is  to  be  seen  in  medical  practice  and 
which  depends  on  the  peculiarities  in  the  course  and  develop- 
ment of  the  tuberculosis  itself,  and  on  the  complicating  diseases 
and  the  peculiarities  of  the  affected  organs,  is  far  from  being 
exhausted  by  the  cases  we  discussed ;  but  not  only  in  the  clinic, 
not  even  in  a  systematic  text-book  of  internal  diseases,  un- 
less it  be  in  a  special  monograph,  can  this  multiplicity  be  ex- 
hausted, or  a  complete  picture  of  all  the  various  forms  of  chronic 
tuberculosis  of  the  lungs  to  be  seen  in  medical  practice,  be  pre- 
sented. 

I  consider  it,  however,  useful  to  outline  before  you  now,  after 
we  have  discussed  the  previous  cases,  a  clinical  picture  of  those 
varieties  of  the  disease,  which  we  had  no  opportunity  to  bring 
before  you,  at  least  the  most  important  ones ;  my  aim  in  doing 
this  is,  that  the  cases  presented  to  you  alongside  with  these 
forms,  as  well  as  these  last  side  by  side  with  the  presented 
cases,  might  become  more  salient,  and  might  be  better  and  more 
strongly  impressed  on  your  memory,  than  is  usually  the  case 
when  pathology  is  studied  systematically,  but  without  the  aid 
of  a  clinic. 


-     285  — 

The  last  stage  of  chronic  tuberculosis  of  the  lungs  is  pulmon- 
ary phthisis,  phthisis  declarata.  You  had  occasion  to  see  a  suffi- 
cient number  of  such  patients  both  in  our  clinic  and  in  the 
propsedeutic  clinic  when  you  were  engaged  in  studying  the  ob- 
jective examination  of  the  diseases  of  the  organs  of  respiration ; 
you  are  familiar  with  the  sharp  local  changes,  with  the  charac- 
teristic abundant  expectoration,  containing  great  numbers  of 
tuberculous  and  other  bacteria  and  elastic  fibres  of  the  broken- 
down  pulmonary  tissue,  and  also  with  the  characteristic  habitus 
of  such  patients  :  their  extreme  emaciation,  their  great  debility 
(the  patients,  when  seen,  are  always  in  the  recumbent  posture), 
the  high  jumps  and  the  low  falls  of  the  temperature,  the  ex- 
hausting sweats.  How  great  is  the  difference  between  these 
and  the  cases  of  chronic  tuberculosis  of  the  lungs  in  its  in- 
cipient, or  frequently  even  in  its  advanced  development, 
when  the  patients,  only  slightly  or  not  at  all  emaciated,  with 
but  a  slight  cough,  without  a  constant  or  considerable  fever 
(only  a  trifling  rise  of  the  temperature  toward  the  evening 
without  QMj  considerable  fall  in  the  morning), —  are  not  only 
not  confined  to  bed,  but  are  actively  occupied  with  their  affairs, 
and  look  simply  like  men  whose  health  is  not  quite  up  to  the  or- 
dinary, but  by  no  means  like  pronouncedly  sick  people.  I  will 
stop  here  to  discuss  the  importance  of  the  exhaustive  fever  — 
the  febris  hectica  —  seen  in  phthisical  patients,  which  is  so 
characteristic  by  the  high  jumps  and  the  low  falls  of  the  tem- 
perature, and  also  by  the  sweatings  which  accompany  these 
last.  As  is  well  known,  the  expectoration  of  phthisical  patients 
contains,  besides  the  tubercle  bacilli,  also  numbers  of  other 
micro-organisms  to  which  is  ascribed  the  pernicious  influence 
on  the  organism  of  the  patient,  and  which  are  considered  as 
the  cause  of  the  last,  phthisical  stage  of  chronic  pulmonary 
tuberculosis  ;  but  until  recently  the  nature  of  the  special  micro- 
organism, which  is  accountable  for  this  pernicious  influence, 
has  not  been  thoroughly  mvestigated.  Exact  investigations 
touching  upon  this  subject  have  lately  appeared  from  the  Insti- 
tute for  Contagious  Diseases  under  the  supervision  of  Prof.  Koch 
at  Berlin.  (Petrushky,  Tuberculose  und  Septiccemie,  Deutsche 
med.Wochenschrift,  1893,  No.  14.) 


^  286  — 

In  the  expectoration,  which  was  subjected  to  a  certain  process, 
■  by  which  everything  that  was  mixed  with  it  in  the  cavity  of 
the  mouth  was  removed,  there  were  found  much  smaller  num- 
bers of  bacteria,  than  in  the  expectoration  which  was  mixed 
with  the  saliva ;  it  was  found  that  this  expectoration,  free  from 
saliva,  contains  principally  tubercle  bacilli,  and  of  the  others 
the  most  constant  and  the  most  abundant  were  the  pyogenic  or- 
ganisms, namely,  the  streptococci.  They  were  also  found  in 
the  tissue  of  the  lungs  and  other  organs,  and  also  in  the  blood 
of  dead  phthisical  persons,  so  that,  according  to  Koch,  the  last 
stage  of  chronic  pulmonary  tuberculosis  presents  already  a  com- 
plication of  this  last  by  a  secondary  infection  of  the  organism 
through  streptococci,  which  enter  the  body  through  the  ulcer- 
ated spaces  (the  cavernse)  in  the  lungs,  in  a  way  very  similar  to 
that  in  which  they  infect  the  organism  when  entering  through 
wounds.  It  thus  becomes  clear,  why  the  fever  in  the  last  stage 
of  chronic  tuberculosis  of  the  lungs  has  the  identical  features  of 
that  seen  in  septic  wound  mfections.  Koch  calls  the  tempera- 
ture curve  in  this  fever,  for  brevity's  sake,  streptococcus  curve 
(Streptococcencurve.)  * 

Pneumoyiice  complicating  chronic  ful'monary  tuberculosis.  —  Fi- 
brinous (croupous^  pneuononia  occurs,  although  very  rarely,  in 
chronic  tuberculosis  of  the  lungs  and  is  easily  diagnosticated, 
especially  if  it  affects  a  patient  whom  the  physician  knew  be- 
fore :  in  such  a  case  the  physician  will  be  able  to  detect,  beside 
the  old,  well-known  tuberculous  focus  in  the  apex,  say,  of  the 
right  lung,  also  an  affection  of  the  whole  of  the  inferior  lobe  of 
the  same  or  of  the  other  lung,  as  evidenced  by  the  dull  percus- 
sion sound,  by  crepitation,  bronchial  breathing,  subcrepitation ; 
the  expectoration  will  be  tmged  with  blood  and  will  contain 
along    with  the    tubercle  bacilli,    pneumonic  diplococci,  while 

*  iSTot  all,  however,  entertain  a  similar  view  on  this  subject:  Leyden 
does  not  believe  that  other  micro-organisms,  besides  the  tubercle  bacilli, 
play  any  part  in  the  phthisical  period  ;  he  points  out  the  fact  that  in 
miliary  tuberculosis  and  in  tubercular  caseous  pneumonia  the  fever  is 
very  high,  and  still  we  find  only  tubercle  bacilli,  and  no  other  micro-or- 
ganisms in  these  cases  ;  Frankel  states,  that  in  many  cases  of  tuberculous 
pneumothorax  the  pus  contains  only  tubercle  bacilli  {Berlin.  Klinische 
Wochenschrift,  1893,  :N'o.  42,  pp.  1029-1030). 


—  287  — 

the  temperature  will  rmi  the  course  so  peculiar  to  croupous 
pneumonia.  The  disease  may  terminate  in  recovery  or  death, 
but  if  recovery  takes  place,  there  is  usually  observed  an  aggra- 
vation in  the  course  of  the  tuberculous  process. 

But  more  frequently  chronic  pulmonary  tuberculosis  is  com- 
plicated by  catarrhal  and  caseous  pneumoyiice,  which  are  emi- 
nently peculiar  to  it.  Here  also  the  diagnosis  is  easier,  if  the 
patient  was  known  before.  The  physician  then  observes  simulta- 
neously with  the  sudden  rise  and  the  further  pneumonic  course  of 
the  temperature,  a  rapid  increase  of  the  local  changes  :  the  well- 
known  sign  of  tuberculous  affection,  for  instance,  of  the  apex 
of  the  right  lung,  the  slight  dullness  under  the  very  clavicle, 
with  prolonged  expiration  and  in  the  presence  of  rales,  is  ob- 
served to  be  spreading  to  a  greater  distance  down  to  the  third, 
and  then  to  the  fourth  rib,  and  later  on  further,  becoming  more 
intense  all  the  while ;  the  same  is  observed  in  the  posterior  sur- 
face of  the  chest ;  with  this  there  are  heard  over  the  area  of  the 
dull  percussion  sound  rales  and  bronchial  breathing.  A  whole 
lung  may  thus  become  affected  in  a  short  time ;  but  generally  the 
affection  spreads  at  a  slower  rate  than  in  the  case  of  croupous 
pneumonia,  and,  besides,  usually  from  above  dowTiward,  and  not 
in  the  opposite  direction,  as  ordmarily  occurs  in  croupous  pneu- 
monia. Concerning  the  termination  of  the  disease,  there  are 
cases  in  which  the  pneumonic  fever  keeps  on  but  for  a  short 
time,  the  affection  of  the  lung  is  not  considerable  and  passes 
away  with  the  fall  of  the  temperature,  leaving  traces  of  the 
former  tuberculous  focus,  at  times  slightly  increased ;  in  such 
cases  the  pneumonia  is  very  likely  of  a  catarrhal  nature.  In 
other  cases  the  affection  of  the  lungs  spreads  to  a  considerable 
extent  and  does  not  become  limited,  the  high  temperature  of  a 
pneumonic  character,  with  its  slight  difference  between  morning 
and  evening  does  not  fall,  and  the  patient  succumbs  after  a  few 
weeks  (four  to  eight)  from  the  commencement  of  the  pneumonia. 
Autopsy  shows  in  these  cases  a  considerable  caseous  pneumonia, 
which  terminated  in  the  destruction  of  pulmonary  tissue  and 
the  formation  of  cavities.  These  are  the  cases  of  what  the 
Frenchmen  call  galloping  pulmonary  phthisis. 

There  was  one  such  case  that  has  left  a  particularly  strong 


—  288  — 

impression  on  my  mind.  The  patient,  whom  I  have  known  for 
•several  years,  had  small  tubercular  foci  in  both  pulmonary 
apices,  at  times  expectorated  blood  and  was  feverish,  but  had 
nevertheless  enjoyed  fair  health  and  was  very  active.  After 
one  certain  period  of  time,  unfavorable  to  his  health  (after  a  fa- 
tigue and  a  cold),  his  temperature  rose  suddenly  and  the  area  of 
dullness  under  the  right  clavicle  began  to  spread  downward 
and  also  on  the  posterior  surface  of  the  right  half  of  the 
chest.  During  six  weeks,  until  the  patient's  death,  the  tempera- 
ture vacillated  constantly  between  S9°B.  (102°F.)  and  39.5°  i^. 
(10SA°F.')  m  the  mornmg  and  39.5°i^.  (103.1°!^.)  to  4:0°R. 
(104°J^'.)  in  the  evening,  while  the  right  lung  was  almost  com- 
pletely affected. 

It  is  thus  evident  that  the  clinical  pictures  j^i'esenting  the 
pneumonic  complications  of  pulmonarj^  tuberculosis,  the  or- 
dinary course  of  this  last  and  its  last  phthisical  stage,  differ  one 
from  the  other,  and  enable  one  to  recognize  these  various  mor- 
bid conditions. 

Acute  miliar^/  tuberculosis  of  the  lungs  may  also  be  superadded 
to  chronic  tuberculosis  (i.  e.  to  chronic  tubercular  broncho-pneu- 
monia), and  its  clinical  picture  differs  also  from  the  clinical  pic- 
tures of  the  usual  course,  of  the  last  stage  and  of  the  pneumonic 
complications  of  this  last ;  it  is  rather  similar  in  its  clinical  as- 
pects to  an  irregular  typhoid  fever ;  but  it  is  more  opportune 
to  discuss  acute  miliary  tuberculosis  in  general  and  that 
of  the  lungs  in  particular  when  we  chance  to  come  across,  if  not 
a  case  of  this  comparatively  rare  disease,  then  one  of  typhoid 
fever. 

The  most  important  complications  of  chronic  tuberculosis  of 
the  lungs  by  affections  of  other  organs,  outside  of  those  we  dis- 
cussed above,  are  pneumothorax  and  pyopneumothorax,  tubercu- 
losis of  the  larynx,  and  intestinal  tuberculosis.  Clinical  pictures 
of  these  diseases  enable  one  to  fully  recognize  their  presence. 

As  regards  the  peculiarities  in  the  clinical  picture  and  in  the 
course  of  chronic  pulmonary  tuberculosis,  which  are  determined 
by  the  peculiarities  of  the  affected  organs,  I  will  only  note  the 
following.  Persons  who  fall  victims  to  chronic  tuberculosis  of 
the  lungs  may  be  subdivided  into  three  classes  :  there  are  those 


—  289  — 

who  are  by  nature  of  a  weak  constitution,  with  a  narrow  and 
flat,  under-developed  chest  (in  proportion  to  their  height) ; 
they  frequently  come  from  as  weak  and  even  tuberculous  par- 
ents, and  present  but  too  evident  a  predisposition  to  tubercu- 
losis of  the  lungs ;  others,  on  the  contrary,  who  were  formerly 
of  a  strong  constitution,  robust,  and  enjoyed  the  best  of  health, 
become  affected  by  pulmonary  tuberculosis  after  their  health 
had  been  previously  undermined,  most  frequently  by  syphilis, 
alcoholism,  prolonged  and  severe  malaria,  or  diabetes  mellitus  ; 
quite  often  these  persons  succumb  sooner  than  those  belonging 
to  the  other  categories  (m  those  previously  affected  with  dia- 
betes mellitus  the  course  of  pulmonary  tuberculosis  is  always 
liable  to  be  unusually  rapid,  more  so  than  in  any  other  case)  ; 
lastly,  persons  of  the  third  class  do  not  present  the  character- 
istic peculiarities  of  either  of  the  above  two  classes. 

Prognosis  of  chronic  tuberculosis  of  the  lungs.  —  I  must  repeat 
what  I  took  occasion  to  say  two  years  ag-o  while  comparing  the 
treatment  of  pulmonary  tuberculosis  by  injections  of  Koch's 
tuberculin  (discussed  at  that  time)  with  the  treatment  of  this 
disease  by  the  usual  method,  with  the  aid  of  creosote,  arsenic, 
koumyss  and  cod-liver  oil,  in  connection  with  the  necessary  symp- 
tomatic treatment,  for  the  removal  of  difficult  and  exhausting 
symptoms,  and  with  correct  hygienic  measures,  including,  of 
course,  the  climate.  I  said  then :  "  What  results  did  we  obtain 
from  this  treatment  ?  What  experienced  physician  has  not  ob- 
served, even  in  the  advanced  —  but  certainly  not  in  the  last  — 
stage  of  pulmonary  tuberculosis  a  considerable  improvement 
for  a  period  of  years,  and  in  the  incipient  period,  a  complete 
recovery  of  the  general  health  ad  integrum,  while  all  the  local 
symptoms,  subjective  and  objective,  disappear  unless  there  re- 
mains only  a  slight  difference  between  the  respiratory  murmur 
over  the  apex  of  the  healthy  lung  and  that  of  the  affected  one  ? 
What  experienced  physician  has  not  noticed  that  such  a  re- 
covery of  health,  such  a  cure,  may  last  for  years  ?  I  had  occa- 
sion to  keep  under  observation  such  recovered  patients  for  pe- 
riods of  from  five  to  ten  years,  before  I  lost  track  of  them.  It 
is  true,  that  at  times,  after  several  years  of  such  a  favorable 
condition,  the  patient  will  reappear  again  with  symptoms  of  pul- 


—  290  — 

monary  tuberculosis ;  but  it  can  usually  be  proved  that  this 
.fresh  reappearance  of  the  symptoms  has  been  preceded  by  a 
weakening  in  the  general  condition  of  health,  because  of  an  ir- 
regular mode  of  living,  unsatisfactory  circumstances,  or  an  attack 
of  some  painful  disorder;  it  thus  remains,  in  such  cases,  to  decide 
whether  all  this  was  due  to  the  lighting  up  of  the  old  focus,  or 
to  the  appearance  of  a  fresh  infection.  Finally,  such  a  method 
of  treatment,  whether  it  result  in  the  above-outlined  favorable 
issue  or  not,  is  neither  risky  nor  fraught  with  any  danger,  as  is 
so  frequently  the  case  during  the  treatment  by  injections  of 
tuberculin." 

The  slighter  the  local,  i.  e.  the  pulmonary  affection,  and  the 
better  the  general  condition  of  health,  and  the  less  the  number 
of  complications,  —  the  better  is,  of  course,  the  prognosis,  and 
contrariwise  (although  there  are  exceptions  to  this). 

As  to  what  concerns  the  influence  on  the  prognosis  of  diseases 
developed  before  the  occurrence  of  the  chronic  pulmonary 
tuberculosis,  we  may  say  that  it  is  particularly  unfavorable 
in  cases  where  the  pulmonary  tuberculosis  seizes  upon  an 
organism  previously  affected  by  diabetes  mellitus,  and  also  by 
syphilis.  However,  in  the  last  case,  in  persons  of  a  strong 
constitution,  we  may  sometimes  succeed,  after  having  influenced 
the  syphilis  effectively  by  the  iodides  or  less  frequently  by  mer- 
cury, in  obtaining  some  good  results  by  the  usual  treatment 
of  the  pulmonary  tuberculosis.  (Vide  article  on  "•'  Syphilis  of  the 
Lungs.") 

TREATMENT  OF  CHRONIC  PULMONARY  TUBER- 
CULOSIS, 

Do  we  possess  a  remedy  against  chronic  pulmonary  tubercu- 
losis, which  may  be  called  specific?  Before  we  present  an 
answer  to  this  question,  we  must  say  that  the  nature  of  a 
specific  has  not  been,  as  yet,  clearly  defined.  Thus,  as  the  most 
typical  specific  remedy,  we  consider  quinine  in  malaria,  which 
last  is  an  infectious  disease ;  whereas  modern  medicaliescn  ce 
searches  for  specific  remedies  against  infectious  diseases  in 
the  products  of  the  vital  activity  of  the  micro-organisms,  which 


—  291  — 

are  considered  as  the  causative  agencies  of  these  diseases; 
consequently  these  remedies  are  of  a  nature  totally  different 
from  that  of  quinine.* 

Such  being  the  condition  of  things,  I  can  only  define  the 
nature  of  a  specific  remedy  in  the  words  I  spoke  while  dis- 
cussing the  treatment  of  cholera :  "  a  specific  remedy  is  not 
one  which  exerts  its  effect  upon  one  certain  symptom  of  the 
disease,  but  one  that  strikes,  so  to  say,  the  very  centre  of  this 
last,  and  by  acting  at  once  on  all  the  symptoms,  breaks  them 
up,  causing  a  cessation  of  the  disease,  as  quinine  does  in 
malaria,  and  sodium  salycilate  in  acute  articular  rheumatism." 
If  we  are  to  regard  a  specific  drug  from  such  a  point  of  view, 
then  there  is  no  doubt  that  we  have  no  drug  whose  effect 
in  tuberculosis  could  be  comparable  to  the  action  of  quinine 
in  malaria ;  but  the  effect  produced  by  creosote  in  tuberculosis 
is  such  that  it  cannot  be  called  symptomatic  only ;  its  action  is, 
besides,  evident  only  in  tuberculosis  or  in  cases  of  predisposi- 
tion to  the  same,  and,  as  far  as  I  know,  in  no  other  disease. 
-  Let  us  now  turn  to  the  treatment  of  tuberculous  patients 
as  based  upon  facts. 

Symptomatic  treatment^  by  which  we  mean  the  removal  of  all 
the  distressing  and  debilitating  symptoms,  plays  an  important 
part.  During  the  discussion  of  the  previously  presented  cases 
of  chronic  tuberculosis  of  the  lungs  I  had  occasion  to  speak 
of  the  treatment  of  all  the  symptoms  of  this  nature,  except 
haemoptysis  and  fever,  which  I  will  take  up  presently. 

During  haemoptysis  the  patient  must  preserve  quietude 
and  be  silent.  If  there  are  no  contra-indications,  in  the  form 
of  a  diarrhoea  or  extreme  debility  of  the  patient  or  in  the  degree 
of  the  haemoptysis,  we  must  first  of  all  administer  a  laxative 
(an  eccoprotic,  not  a  drastic)  and   then    secale  cornutum,  an 

*  Let  me  recommend  you  an  interesting,  altliougii  somewhat  verbose 
and  lengthy  (a  common  fault  of  the  majority  of  modern  writers)  article 
of  Behring's  (Prof.  Behring,  "  Die  atiologisch-therapeutische  Bestre- 
bungen  der  Gegenwart,"  Deitisc/ze  med.  Wocftenschrift,  1893),  in  which  the 
author,  being  a  partisan  of  Koch's,  criticises  sharply,  but  nevertheless 
judiciously,  the  general  pathological  and  therapeutic  positions  of  Vir- 
chow,  which  once  played  an  important  role,  and  discusses  the  question 
of  the  specific  treatment  in  its  past  and  present  condition. 


—  292  — 

infusion  of  3ij  to  3vj,  a  tablespoonful  every  hour;  to  quiet  the 
■cough  codeiae  or  morphine.  For  habitual,  repeated  haemop- 
tysis two  to  three  leeches  to '  the  coccyx  (vide  article  on 
''  Blood-letting  "). 

If  the  fever  is  not  considerable  and  the  rise  of  temperature  does 
not  exceed  38°  (100.4°  i^.),  then  there  is  usually  no  necessity 
for  the  employment  of  special  measures  in  combattmg  it :  the 
creosote  treatment,  by  causing  a  general  improvement,  causes 
also  a  cessation  of  the  fever.  But  in  case  the  fever  is  more 
considerable,  then,  at  the  commencement  of  the  creosote  treat- 
ment, before  it  has  as  yet  an  opportunity  to  exert  its  effects,  I 
prescribe  for  the  mornmg,  during  the  fall  of  the  temperature,  five 
to  ten  grains  of  quinine,  and  in  the  evening,  during  the  rise  of  the 
temperature,  four  to  eight  grains  of  phenacetine,  less  frequently 
three  to  five  grams  of  antifebrine,  and  still  less  so  ten  to  twenty 
grains  of  sodium  salycilate,  and  very  rarely  antipyrin.  Most 
frequently  we  have  to  admmister  antipyretic  drugs  in  the  last 
stage  of  chronic  tuberculosis  of  the  lungs  and  during  its 
pneumonic  complications,  to  administer  them  of  course  until 
a  marked  lowering  of  the  temperature  is  effected,  but  not  until 
it  be  brought  down  to  the  normal ;  this  last  is  frequently  im- 
possible, always  useless,  and  besides  risky,  as  it  requires  large 
doses  of  the  mentioned  antipyretics,  and  may  thus  cause  a 
dangerous  weakening  of  the  heart. 

The  most  important  part  is  played  by  improvement  in 
the  nutrition  (and  this  is  usually  accompanied  by  an  increase 
of  patient's  strength),  whether  it  result,  in  connection  with  the 
successful  employment  of  the  symptomatic  treatment,  from 
the  application  of  hygienic  measures  only  or  from  them  and  the 
additional  use  for  this  purpose  of  various  remedial  agencies, 
the  most  important  of  which  are  koumyss  and  creosote.  It  is 
only  with  the  aid  of  improved  nutrition  and  strength,  that  we 
obtain  the  good  results  to  which  we  alluded  in  discussing  the 
prognosis. 

Koumyss.  —  Until  the  time  when  large  doses  of  creosote 
were  introduced  into  medical  practice  for  the  treatment  of 
chronic  pulmonary  tuberculosis,  koumyss  was  considered  the 
best  means  for  improving,  in  a  very  short  time,  the  nutrition 


—  293  — 

and  strength,  and  also  the  local  symptoms.  But  since  then, 
koumyss  has  become  less  important.  First,  because  creosote,  al- 
though somewhat  slower,  gives  the  same  results ;  and  whereas 
the  koumyss  treatment  is  only  possible  during  the  three  sum- 
mer months  (from  the  middle  of  May  till  the  middle  of  August) 
after  which  it  must  be  interrupted  for  nine  months,  during 
which  time  the  obtained  results  are  either  partly  or  entirely 
lost,  the  treatment  with  creosote  can  be  continued  constantly, 
only  with  those  short  (about  one  month)  interruptions,  which 
are  required  by  the  peculiarities  of  the  creosote  treatment  itself. 

Secondly,  the  treatment  with  creosote  is  incomparably  more 
accessible  than  a  trip  to  the  koumyss  sanatarium,  which  in- 
volves considerable  expense,  worry,  and  finally  the  risk  of  not 
being  able  to  obtaui  good  koumyss,  or  good  board,  lodging, 
etc. 

It  would,  however,  be  erroneous  to  assume  that  koumyss  has 
entirely  lost  its  importance.  There  may  occur  many  cases  in 
which  the  koumyss  treatment  is  both  more  convenient  for  the 
patient  and  indicated  either  during  the  interruption  in  the  cre- 
osote treatment  or  when  this  last  is  not  well  borne  or  does  not 
give  the  expected  result,  which  last  circumstance  occurs,  how- 
ever, only  in  the  minority  of  cases  treated  by  creosote.  Moreover, 
koumyss  is  beneficial  in  the  treatment  of  other  diseases,  out- 
side of  chronic  pulmonary  tuberculosis.  It  constitutes  an  unre- 
placeable  medicinal  agency  for  effecting  a  rapid  recovery  of 
health  which  has  suffered  from  serious  maladies  or  from  a  pro- 
longed residence  under  unfavorable  hygienic  conditions.  Fi- 
nally, koumyss  is  useful  not  only  for  improving  the  health,  but, 
by  causing  a  sound  and  prolonged  sleep,  for  its  strong  effect  up- 
on the  nervous  system :  koumyss  is  an  excellent  remedial  agent 
in  neurasthenia.  If  the  neurasthenic  patient  is  not  thin,  the 
more  so  if  he  be  stout,  then  the  best  thing  for  him  is  bathing  in 
the  river,  and,  even  better  still,  in  the  sea  (up  to  a  certain  age, 
after  which  baths  at  the  temperature  of  27°i?.  (92.8°  i^.)  are 
more  suitable ;  of  this  we  shall  speak  in  due  time)  ;  but  if  the  nu- 
trition of  the  neurasthenic  patient  has  failed  considerably,  then 
bathing  may  become  very  harmful  to  him,  while  the  baths  at 
21° R.  (92.8°#.),  even  if  harmless,  will  be  but  of  little  benefit 


—  294  — 

and  but  for  a  short  time,  during  the  employment  of  these  baths  ; 
whereas  koumyss  in  such  cases,  by  improving  the  nutrition  and 
by  exerting  a  powerful  influence  on  the  nervous  system,  may 
bring  about  a  complete  recovery  of  health.  In  the  same  cases  of 
neurasthenia,  which  are  accompanied  by  a  failure  of  nutrition, 
koumyss  by  its  effects  is  superior  to  the  best  apothecary  drugs 
used  against  neurasthenia,  as  arsenic  and  silver  nitrate  ;  (these 
last  are  preferred  to  koumyss  only  because  they  may  be  used 
at  any  time  of  the  year).  I  will  add  here,  that  we  meet  very 
often  cases  of  neurasthenia  complicating  chronic  pulmonary 
tuberculosis. 

While  speaking  of  the  koumyss  treatment,  I  mentioned  trips  to 
the  koumyss  sanatoria.  This  must  be  explained.  The  fame 
of  koumyss  as  a  curative  agency,  a  fame  which  is  fully  merited, 
as  I  can  testify  also  by  my  own  practical  experience,  has  origi- 
nated in  the  locality  between  the  Volga  and  the  Oural.  There 
existed  before,  and  there  exist  to  an  extent  now,  vast  feeding 
grounds,  which  make  it  possible  to  breed  horses  in  great  herds  ; 
the  summer  there  is  mostly  dry  and  warm,  even  hot.  Only 
during  such  a  summer  can  the  patients  use  the  considerable 
quantities  of  koumyss,  so  necessary  for  obtaining  good  curative 
results  ;  only  at  such  localities,  from  such  an  abundance  of  young 
healthy  mares,  which  are  not  used  for  labor,  but  feed  on  the 
abundant  pasture-grounds,  will  the  patients  obtain  good  kou- 
myss in  a  sufficient  quantity.  The  attempts  to  resort  to 
koumyss  treatment  in  the  absence  of  such  conditions,  even  in 
the  cities  (compare  the  air  of  the  city  with  that  of  the  field) 
or  even  during  the  winter  (!)  months,  give,  of  course,  miserable 
results,  and  are  usually  harmful  (as  the  koumyss  is  not  borne 
well  and  causes  a  diarrhoea),  and  has  surely  no  claim  to  be  re- 
garded as  koumyss  treatment.* 

Treatment  with  cod-liver  oil  (during  the  cold  season  of  the 
year),  with  keffir,  less  frequently  with  milk  and  the  farinaceous 
preparations,  may  serve  as  a  good  aid,  in  improving  the  nutrition, 
to  the  other  treatment,  but  it  certainly  cannot  be  compared  to 
the  genuine  koumyss  treatment. 

*  Prof.  IST.  F.  Goluboif  has  written  a  great  deal  on  the  subject  of  kou- 
myss treatment. 


—  296  — 

The  treatment  with  arsenic  was  spoken  of  before,  and  particu- 
larly its  use  in  chlorosis  and  chloransemia  with  a  predisposi- 
tion to  pulmonary  tuberculosis. 

Creosote^  guaiacol^  OA'idi  guaiacol  carhonate.  —  How  these  reme- 
dies exert  their  effects  —  whether  directly  on  the  tuberculous 
bacilli  (which  is  denied  by  some)  or  only  by  strengthening  the 
organism,  and  thus  diminishing  the  predisposition  to  the  devel- 
opment of  these  last  —  is  not  known  ;  but  the  fact  that  they 
are  effective  is  beyond  any  doubt,  and  is  recognized  as  such  by 
a  majority  of  most  competent  practitioners.  My  own  practical 
experience  speaks  in  favor  of  the  subject  in  a  similar  manner. 
There  are  also  heard  dissenting  opinions,  which  are  due  partly 
to  insufficient  observations,  and  partly  to  the  fact  that  the  creo- 
sote, guaiacol  and  its  carbonate  are  not  always  of  the  best 
quality,  and  do  not  always  have  the  same  constituents.  The 
effect  itself  of  these  remedies  consists  in  this,  that  as  a  result 
of  their  prolonged  and  gradually  increased  use,  the  appetite  is 
improved,  the  former  slight  dyspeptic  symptoms  disappear,  the 
nutrition  and  strength  improve  considerably,  at  times  strikingly 
so,  and  together  with  these,  also  the  local  symptoms. 

The  above-named  remedies  are  used  at  the  beginning  in  small 
and  later  on  in  gradually  increasing  doses,  as,  for  mstance,  creo- 
sote or  guaiacol  at  first  five  drops  (guaiacol  carbonate  five 
grains),  once  a  day,  and  later,  more  and  more  frequently,  alwaj^s 
after  a  meal,  and,  when  taking  frequent  doses,  if  not  after  a 
meal,  then  in  a  half-glassful  of  milk ;  if  they  are  taken  in  ca- 
chets or  capsules,  then  one-fourth  of  a  glass  of  milk  is  taken 
before  the  capsule  and  another  one-fourth  after  it.  The  ra- 
pidity with  which  the  dose  is  to  be  increased  depends  on  how 
well  the  remedies  are  borne  and  on  theii"  effects  ;  if,  after  taking 
them,  there  is  felt  an  unpleasant  heaviness  in  the  stomach  and 
the  appetite  is  not  improved,  then  the  dose  remains  the  same  ; 
but  if,  as  usually  happens,  the  appetite  is  improved,  and  there 
is  no  heaviness  in  the  stomach,  but  on  the  contrary  even  the 
formerly  present  —  before  the  beginning  of  the  treatment  — 
dyspeptic  symptoms  disappear,  then  the  dose  is  increased  up  to 
thirty,  sixty,  and  more  drops  in  the  twenty-four  hours.  At 
times  the  treatment  must  be  interrupted,  say,  for  two  to  four 


—  296  — 

weeks  after  two  months  of  treatment;  we  must,  of  course,  in 
doing  so,  take  into  consideration  the  patient's  individuality  and 
the  successful  results  of  the  treatment :  the  more  considerable 
these  last,  the  less  necessity  there  is  for  hurrying  on  with  the 
treatment.  The  interruptions  are  made  with  the  aim  in  view  of 
not  injurmg  the  stomach  and  the  kidneys ;  at  times,  although 
it  may  be  rarely,  during  the  treatment  with  the  above-named 
remedies,  there  is  observed  the  appearance  of  albuminuria,  which 
usually  passes  away  after  the  cessation  —  in  such  cases  necessary 
—  of  their  employment. 

Creosote  and  guaiacol  do  not  present  any  notable  difference 
in  their  effects  :  the  guaiacol  carbonate  is  at  times  better  borne 
by  the  stomach,  but  it  is  high-priced  and  evidently  exerts  a 
weaker  effect  than  creosote  or  guaiacol ;  such  is  at  least  my  im- 
pression, received  from  its  use  in  several  cases. 

We  are  rarely  compelled  to  mtroduce  creosote  or  guaiacol  in- 
to the  system  through  other  ways  than  the  stomach.  The 
slight  dyspeptic  symptoms,  so  frequently  seen  in  patients  with 
chronic  pulmonary  tuberculosis,  depend  usually  upon  the  gene- 
ral weakening  of  nutrition,  of  the  function  of  hgematopoiesis 
and  of  the  nervous  system,  and  are  not  due  to  a  chronic  gas- 
tric catarrh ;  a  gradual  and  carefully  conducted  treatment  with 
guaiacol  or  creosote  not  only  usually  ameliorates  these,  but 
with  the  improvement  in  the  general  condition,  the  symptoms 
pass  away  entirely.  But  if  these  dyspeptic  symptoms  be  con- 
siderable, then  we  can  usually  succeed  in  removing  them  by 
preliminary  treatment,  and  bring  the  stomach  into  a  condition 
which  would  enable  it  to  bear  well  creosote,  guaiacol,  or  at  least 
guaiacol  carbonate,  as  was  the  case  with  our  patient  who  suffered 
with  chloraucemia  and  incipient  tuberculosis  (vide  18th  case). 
But  still  I  had  occasion  to  observe  a  case  of  chronic  pulmonary 
tuberculosis  complicated  by  a  very  obstinate  chronic  gastric  ca- 
tarrh of  an  independent  origm,  not  due  to  the  pulmonary  trouble, 
in  which  creosote  was  not  borne  by  the  stomach,  even  after  the 
latter  had  been  subjected  to  a  preliminary  treatment,  and  the 
patient  improved  only  after  a  prolonged  introduction  of  great 
quantities  of  creosote  —  dissolved  in  olive  oil  —  by  subcutane- 
ous injections,  usually  into  the  buttocks. 


—  297  — 

The  introduction  of  creosote  through  the  respiratory  tract  is 
usually  badly  borne  (it  causes  severe  coughing),  and  does  not 
produce  even  a  shadow  of  the  effect  which  is  obtained  by  the 
continuous  and  gradually  mcreasing  administration  of  the  drug- 
through  the  stomach.  The  inhalations  of  small  quantities 
of  creosote  are  sometimes  well  borne,  but  outside  of  a  slight 
relief  in  loosening  the  expectoration  and  some  improvement  of 
this  last  (patients  sometimes  find  that  the  expectoration,  dur- 
ing the  inhalation  of  creosote,  is  of  a  less  disgusting  taste  and 
odor),  it  induces  no  marked  change  for  the  better  in  the  local 
symptoms  and  in  the  condition  of  the  affected  portions  of  the 
lungs.  I  may  add  that  the  same  may  l^e  said  also  regarding 
the  other  remedies  of  the  inhalation  therapy,  as  eucalyptus 
oil,  ol.  terebenth.  rectific,  —  which  is  more  beneficial  in  bronchial 
catarrh  complicating  chronic  pulmonary  tuberculosis,  and  cer- 
tainly also  m  a  plain  bronchitis,  —  menthol,  Peruvian  balsam  and 
others. 

All  that  was  said  of  the  use  of  koumyss,  creosote  and  other 
remedies  in  chronic  pulmonary  tuberculosis,  does  not  refer  to 
the  last  stage  of  this  disease  :  at  this  stage  these,  as  well  as  all 
other,  remedies  are  but  little  effective;  we  have  as  yet  no  reli- 
able means  for  the  treatment  of  the  disease  at  this  period. 
When  chronic  pulmonary  tuberculosis  is  complicated  by  catarrh- 
al and  caseous  pneumonia,  then  koumyss  is  of  course  of  no 
avail ;  of  the  use  of  creosote  in  cases  of  these  pneumonic  com- 
plications I  can  say  nothing  :  since  I  am  using  creosote  m  con- 
siderable doses,  I  observed  such  complications  of  chronic 
pulmonary  tuberculosis  but  rarely ;  there  are  no  sufficient  data 
in  the  literature  on  the  subject. 

The  tendency,  so  peculiar  to  modern  medical  bacteriology 
and  which  promises  so  much  for  the  future,  of  searching  in  the 
pathogenic  micro-organisms  themselves,  in  the  products  of  their 
life-activity,  for  means  for  immunization  against  the  diseases 
produced  by  these  micro-organisms,  and  also  for  the  treatment 
of  these  diseases,  has  not  resulted  as  yet,  as  far  as  tuberculosis 
is  concerned,  in  anythmg  of  practical  importance.  I  have  spok- 
en elsewhere  (in  an  article  entitled  "  Treatment  of  tuberculosis 
by  Koch's  tuberculin"  appended  to  the  Russian  edition  of  the 


—  298  — 

lectures)  of  the  thoughtless,  I  may  say  precipitous  treatment 
•of  tuberculosis  by  tuberculin  — ■  an  attempt  the  failure  of  which 
can  only  be  measured  by  the  world-wide  hopes  its  appearance 
has  excited. 

In  passing  from  the  therapy  of  the  patients  suffering  with 
chi'onic  pulmonary  tuberculosis  to  their  hygienic  treatment,  we 
must  principally  take  up  their  climatic  hygiene,  which  is  usu- 
ally, but  less  correctly,  called  climatic  therapy ;  but  the  import- 
ance of  this  subject  and  the  approaching  close  of  the  lecture 
hour  compel  us  to  postpone  it  till  the  next  lecture. 


THE  CLIMATIC  THERAPY  OF  CHRONIC 
PULMONARY  TUBERCULOSIS. 

LECTURE  OF  APRIL  16, 1893. 

For  a  long  time  I  have  made  it  the  business  of  my  clinical 
instruction  to  discuss  this  subject  not  only  in  view  of  its  im- 
portance and  the  entire  ignorance  on  the  part  of  the  students 
about  it,  but  also  because  it  cannot  be  denied,  that  the  majority 
of  the  practitioners  are  but  slightly  acquamted  with  the  sub- 
ject, and  do  not  therefore  prescribe  the  climatic  treatment 
correctly.  On  the  contrary,  as  we  very  frequently  see  by  the 
physicians'  advices,  the  climatic  therapy  is  expected  to  yield 
what  it  cannot,  and  no  advantage  is  taken  of  what  it  can  give. 

Later  on  I  shall  illustrate  my  assertions  by  sufficiently  con- 
clusive examples. 

Before  we  speak  of  the  climatic  therapy  of  chronic  pulmo- 
nary tuberculosis,  we  must  say  a  few  words  regardmg  climate 
and  climatic  therapy  in  general.  Climate  (Gr.  KXt7xa[T-],  a  region, 
zone)  denotes,  properly  speaking,  a  distance  between  two  cir- 
cles parallel  to  the  equator.  In  connection  with  climatic  therapy, 
climate  is  considered  as  the  sum  total  of  all  the  influences  of  the 
given  place,  which  include  its  quantity  of  sunlight,  its  tempera- 
ture, air,  waters,  soil  and  vegetation  ;  besides  these,  in  choosing  a 
certain  locality  with  a  climato-therapeutic  aim  in  view,  we  must 
also  take  into  account  the  various  changes  in  the  above-named 
influences  which  take  place  during  the  various  seasons  of  the 


—  299  — 

year,  and  also  the  conditions  of  life  in  the  given   locality,  — 
the  peculiar  traits  of  its  population,  the  residence,  the  diet,  etc. 
You  thus  comprehend  that  climate  is  something  of  a   very 
complex   and    changeable  nature ;  neither  climatotherapy,  nor 
even  climatology  are  therefore  much  advanced.     Thus,  for  in- 
stance, meteorology  (the  most  important  basis  of  climatology) 
can  foretell  the  condition  of  the  weather  for  the  next  twenty- 
four  hours,  but  is  unable  to  predict  its  condition,  for  the  given 
locality,  for  the  approaching  season  of  the  year,  for  instance,  for 
the  winter,  which  would  be  a  matter  of  great  importance  for 
climatotherapy,  because  the  climate  differs  not  only  during  the 
various  seasons  of-  the  year,  but  during  one  and  the  same  sea- 
son of  the  year  it  is  liable  to  be  variable  in  different  years :  one 
year,  for  instance,  the  winter  is  cold,  the  next  year  it  is  warm, 
or  with  a  clear  and  quiet  weather,  or  rainy,  snowy,  windy,  etc. 
The  complexity  and  inconstancy  of  the  climatic  influences, 
in  the  undeveloped  state  of  climatology,  make  it  impossible  to 
establish  any  satisfactory  climatotherapeutic  classification  of  the 
climates.   Webber,  the  author  of  the  article  on  climatotherapy  in 
the  well-known  collective  edition  of  Ziemssens  Hayidhueh  der  all- 
gemeinen  The^-apie^  states   that  he  was  tempted  to  describe  the 
climatic  sanatoria    in  alphabetical  order,  but  the  necessity  of 
avoiding  repetitions  so  inconvenient  in  a  text-book  prevented 
him  from  domg  this.     As  a  great  many  others,  he  divides  the 
climatic  sanatoria  into  those  situated  near  the  seashore  (these 
again  being  subdivided'into  warm,  cool,  damp  and  dry  ones),  and 
those  situated  inland  (with  subdivisions  into  mountainous  and 
low)  ;    but  this  subdivision  certainly  does  not  do  away  with 
the  necessity,  while  selecting  any  climatic  sanatorium,  for  care- 
fully considering  not  only  its   seaside  or  inland  position,  its 
high  or  low  altitude,  its   warmth  or  coohiess,  but  also  all  the 
remaining    numerous    climatic  and  life   peculiarities   and    the 
manner  of  their  combination,  by  availing  oneself  of   the   aid 
found  in  literature,  or  better  still,  if  possible,  of  the  opportunity 
of  a  personal  acquaintance  with  such  places. 

Such  being  the  condition  of  climatology  and  of  climatother- 
apy, in  discussing  the  special  climatotherapeutic  question, 
namely,  that  of  the  climatic  treatment  of  chronic  pulmonary 


—  300  — 

tuberculosis,  I  consider  it  best,  without  touching  upon  the 
unsatisfactory  division  and  the  characteristics  of  the  climates, 
and  giving  a  short  review  of  the  elements  of  climate  and  its 
therapeutic,  or,  rather,  hygienic,  effect  in  general,  to  give  an  his- 
torical exposition  touching  at  least  the  last  decades  of  the  cli- 
matic treatment  of  chronic  pulmonary  tuberculosis.  I  am  led  to 
think  that  this  will  be  the  best  method  for  explaining  the 
nature  of  the  climatic  treatment  not  only  of  this  disease,  but  of 
the  whole  idea  in  a  general  way,  in  so  far  as  we  can  at  least 
judge  of  this  subject  in  the  present  condition  of  our  knowledge  ; 
I  think  thus,  because,  although  the  question  of  the  climatic 
treatment  of  chronic  pulmonary  tuberculosis  is  but  a  special 
one  in  the  domain  of  climatotherapy,  it  is  undoubtedly  the 
most  important  one.* 


THE  ELEMENTS  OF  CLIMATE, 

The  temiJerature  of  the  locality.  —  Heat  weakens  the  nervous 
system  (causing  fatigue,  disinclination  to  work,  sleepiness), 
the  appetite  and  nutrition.  Cold  excites  the  appetite  keen- 
ly ;  it  is  therefore  unsuitable  for  debilitated  persons  with  poor 
digestive  powers,  who  also  evince  an  inclination  to  colds  and  to 
diseases  dependant  thereon.  Such  patients  are  best  beneiited  by 
localities  with  a  moderate  temperature,  one  which  is  neither 
hot  nor  cold,  and  withal  as  constant  as  possible,  undergoing  but 
few  changes,  because  a  rapidly  and  pronouncedl}-  changeable 
temperature  tends  to  aggravate  and  to  cause  in  such  patients 
cold  and  diseases  resultmg  therefrom.  On  the  contrary,  for 
neurasthenics  a  moderately  changeable  temperature  is  suitable, 
with  moderate  winds,  as,  for  instance,  the  temperature  of  sea- 
side localities ;  of  this  we  shall  speak  when  discussing  balneo- 
therapy. 

*  The  hand-  and  text-books  of  climatotherapy,  besides  the  climatic  ther- 
apy of  chronic  pulmonary  tuberculosis,  usually  mention  this  therapy  for 
the  following  diseases:  catarrhal  and  "rheumatic,"  gout,  scrofulosis, 
various  anaemic  and  nervous  diseases  (neurasthenia,  hypochondriasis, 
etc.) ;  however,  there  are  certainly  but  few  diseases  in  which  correct 
climatic  conditions  would  not  be  of  importance. 


—  301  — 

2.  Moderate  sunlight  acts  beneficially  on  the  mental  condition, 
on  tlie  nervous  system,  and  on  nutrition.  For  winter,  therefore, 
the  localities  where  the  day  is  mostly  clear  are  particularly 
suitable ;  during  summer,  on  the  contrary,  when  there  is  a  su- 
perabundance of  sunlight,  shady,  woody  places  are  preferable. 

3.  The  air.  —  Moisture  in  the  air.  —  Damp  air  is  generally  de- . 
leterious  :  damp  and  hot  air  increases  the  noxious  effect  of 
heat ;  damp  and  cold  air  has  even  a  greater  tendency  to  cause 
cold  and  diseases  due  to  it,  than  cold  air  which  is  not  damp. 
Very  dry  air,  either  warm  or  cold,  irritates  the  mucous  mem- 
branes and  increases  the  tendency  to  cough  and  hsemoptysis. 
An  average  degree  of  moisture  in  the  air  is  therefore  a  necessary 
attribute  of  a  good  climatic  sanatorium.  Considerable  cloudi- 
ness of  the  sky  and  severe  rains  are  harmful,  as  they  increase 
the  amount  of  moisture  in  the  air  and  in  the  soil,  and  tend  to 
decrease  the  amount  of  sunlight,  which  last  is  generally  slight 
during  the  winter ;  but  moderate  rains  are  useful  because  they 
purify  the  atmosphere.     Snow  is  beneficial  for  the  same  reason, 

'and  also  because  the  covermg  of  snow  prevents  the  air  from  be- 
coming contaminated  by  the  various  kinds  of  dust  which  rise 
from  the  ground. 

The  density  of  the  air,  the  pressure  of  the  air.  —  It  is  thought 
that  the  air  of  the  seaside  localities,  under  the  greatest 
pressure  and  therefore  the  densest  and  the  richest  in  oxygen, 
excites  the  appetite  more  readily  than  the  rarefied  air  of  moun- 
tainous localities  at  high  altitudes  ;  but  this  circumstance  is 
usually  counterbalanced  b}^  the  necessity  of  a  greater  amount 
of  physical  exertion,  of  greater  muscular  labor  as  spent  in  fre- 
quent ascensions  in  a  mountainous  locality.  The  considerable 
alterations  in  respiration  and  circulation  observed  on  ascending 
very  high  mountains  or  on  ascending  in  a  balloon  have  no  sig- 
nificance for  climatic  therapy,  because  the  climatic  sanatoria  are 
mostly  located  at  altitudes  between  500  and  1500  meters; 
the  rarefaction  of  the  au-  peculiar  to  such  altitudes  does  not 
produce  to  any  marked  extent  such  influence  on  respira- 
tion and  circulation,  and  on  the  organism  in  general,  as  is  pro- 
duced by  the  rarefied  air  of  the  high  mountains.  The  great 
development  of  the  chest,  so  frequently  observed  in  inhabitants 


—  302  — 

of  the  mountains,  must  be  ascribed  not  to  the  rarefaction  of  the 
mountainous  air  and  the  increased  respiratory  movements  conse- 
quent thereon,  but  rather  to  increased  depth  of  the  same  move- 
ments as  necessitated  by  frequent  ascensions. 

The  motions  of  the  air,  the  winds,  are  of  enormous  importance 
climatically  :  some  winds  carry  with  them  warmth,  moisten  the 
dry  air,  and  clear  the  atmosphere  of  dust ;  others  bring  with 
them  cold  or  heat,  superfluous  moisture  (dampness),  or,  on  the 
contrary,  dryness,  dust.  A  good  climatic  sanatorium  must  be 
protected  from  noxious  winds  by  an  elevation  of  the  land,  or  by 
a  forest. 

The  dem-ness  of  the  air,  the  freedom  from  all  kinds  of  dust, 
inorganic,  organic  dead  and  living  (as  micro-organisms),  is  the 
highest,  most  necessary  requisite  of  a  climatic  sanatorium. 

The  presence  of  ozone  in  the  air  is  beneficial. 

4.  The  soil.  —  The  relief  of  the  soil,  in  the  shape  of  eleva- 
tions or  mountain  ranges,  which^ serve  as  a  protection  against 
noxious  winds,  is  directly  important' in  determining  the  value  of 
a  climatic  sanatorium.  A  damp  soil  predisposes  to  malaria,  is 
deleterious  to  those  suffering  from  catarrhal  and  "  rheumatic  " 
affections,  as  well  as  for  those  afflicted  with  chronic  pulmonary 
tuberculosis,  and  for  many  other  patients.  A  dry  but  bare 
soil,  only  sparsely  covered  with  vegetation,  which  fills  the  air 
with  dust,  is^particularly  harmful  for  patients  with  chest  troubles, 
for  whom  the  best  is  a  dry  soil,  but  one  covered  with  vegeta- 
tion, or,  during  the  cold  season  of  the  year,  with  snow. 

5.  Waters.  —  A  good  water  for  drinking  purposes  is  certainly 
a  necessity  at  a  climatic  sanatorium.  The  neighborhood  of  the 
sea,  which  moistens  the  atmosphere,  purifies  it  by  the  aid  of  an 
almost  constant  wind,  modifies  the  extremes  of  temperature,  at 
times  warms  the  locality,  as  by  warm  sea-currents,  and  presents 
frequently  the  possibility  of  profiting  by  the  beneficial  —  as  for 
neurasthenics — sea-bathing  —  through  all  these  influences  forms 
a  very  important  preference  for  a  climatic  sanatorium. 

6.  The  vegetation,  by  covering  the  soil,  prevents  the  forma- 
tion of  dust,  and  by  absorbing  the  carbonic  acid  and  yielding 
up  the  oxygen,  purifies  the  air  and  assists  in  the  formation  of 
ozone.     Forests  form  an  excellent  protection  against  the  winds 


—  303  — 

and,   during  the  summer,  against  tlie    excessive    heat   of   the 
sun. 

7.  The  heauty  of  the  locality  (the  view  on  the  sea,  moun- 
tains, etc.)  exerts  a  favorable  psychical  influence  and  plaj^s  by 
no  means  an  unimportant  part  in  the  selection  of  a  sanatorium. 

8.  The  value  of  a  trip  to  a  sanatorium,  that  is,  the  import- 
ance of  removing  the  patient  from  the  habitual  conditions  of 
life  (at  times  unfavorable,  as,  for  instance,  an  unhealthy  locality, 
excessive  occupation,  worries,  etc.)  and  of  a  change  in  the 
mode  of  living,  by  instituting  exercises  in  the  open  air,  and  also 
the  importance  of  the  conditions  surrounding  the  life  at  a  cli- 
matic sanatorium  —  partly  needs  no  explanation,  and  was,  to 
some  extent,  already  spoken  of  when  we  discussed  the  internal 
use  of  mineral  waters ;  we  shall  also  touch  upon  the  subject 
later  on,  as  well  as  when  we  come  to  discuss  the  subject  of  bal- 
neotherapy. 

We  will  now  take  up  the  climatic  treatment  of  chronic  pul- 
monary tuberculosis. 

Up  to  within  the  fifties  of  the  present  century  its  treatment 
consisted  chiefly  in  this,  that  the  patients,  during  the  cold  season 
of  the  year,  were  sent  away  to  localities  with  a  prevailing  warm 
climate,  at  first  to  places  on  the  shore  of  the  Mediterranean  Sea 
protected  by  the  Alps  from  the  cold  winds  (the  Riviera),  as 
Cannes,  Nice,  Mentone,  San  Remo,  etc.,  and  later  on  to  neigh- 
boring places  around  Cairo  (Heluan),  Algeria  and  to  the 
Madeiras.  In  these  localities,  besides  the  warmth  and  the  protec- 
tion from  the  cold  winds,  there  was  greatly  appreciated  the 
absence  of  sharp  variations  in  the  temperature.  Finally  patients 
with  a  dry  cough  and  with  an  inclination  to  haemoptysis  were 
advised  to  avoid  localities  with  dry  air,  as,  for  example,  the  en- 
vironments of  Cairo,  and  to  go  to  places  where  the  air  is  suffi- 
ciently moist  (as,  for  instance,  Madeira),  while  for  patients  with 
abundant  expectoration,  on  the  contrary. 

Some  thirty-five  years  ago,  the  physicians  of  Europe  turned 
their  attention  to  the  treatment  of  chronic  pulmonary  tubercu- 
losis by  residence  in  the  mountains.  Observations  in  mountain- 
ous localities  induced  them  to   do  so:   thus  it  was  found  that 


—    304  — 

in  Peru,  where  at  the  seaside  localities  the  above-named 
disease  is  seen  frequently,  and  where  it  rapidly  brings  on 
a  fatal  termination,  a  residence  for  the  patients  during  a  long 
period  in  the  mountainous  plains  —  at  the  altitude  of  3000 
meters  —  in  the  neighboring  Andes  has  been  considered  since  a 
long  time  as  the  ordinary  and  only  successful  treatment. 

Meeting  with  scarcely  any  cases  of  chronic  pulmonary  tuber- 
culosis at  such  high  altitudes,  observers  came  to  the  conclusion 
that  the  success  of  this  treatment,  consisting  of  a  prolonged  res- 
idence in  plains  situated  at  high  altitudes,  depends  on  the  pres- 
ence m  such  localities  of  a  peculiar  "  immunity  "  as  regards 
the  above-named  disease.  The  principal  element,  which  was 
considered  as  exerting  a  favorable  influence  on  the  patients 
suffering  from  chronic  pulmonary  tuberculosis  during  their  resi- 
dence on  high  altitudes,  was  the  rarefaction  of  the  air,  which,  as 
it  were,  excited  increased  respiratory  movements,  brought  about 
a  better  ventilation  of  the  air,  and  tended  to  develop  the  chest, 
etc.  But  neither  supposition  was  found  to  be  true.  It  was 
proved  that  pulmonary  tuberculosis  is  also  met  with  in  moun- 
tainous localities,  although  there  it  is  of  much  rarer  occurrence 
thanks  to  the  absence  of  factory  life  and  similar  conditions,  the 
population  not  being  huddled  together,  as  in  localities  with  a 
dense  population,  under  unfavorable  conditions  of  life ;  while  at 
the  same  time  it  was  found,  that  even  in  Switzerland,  in  the 
factory  districts,  situated  as  they  are  on  high  altitudes,  there  is 
quite  a  number  of  consumptives.  The  importance  of  rarefied 
air  in  climatic  mountain  sanatoria  has  been  spoken  of  before. 

The  German  physician  Brehmer,  deeply  convinced  of  the 
curative  properties  of  the  climate  of  mountainous  localities  for 
tuberculous  patients,  was  the  first  to  establish,  or  he  thought 
he  established,  such  a  sanatorium ;  I  said  he  thought  because  the 
place  selected  by  him,  in  the  vicinity  of  the  village  of  Gorbers- 
dorf,  in  Silesia,  at  an  altitude  of  hardly  550  meters,  can  not  be 
called  a  truly  mountainous  locality.  But  even  without  the 
features  of  a  really  mountainous  place,  Gorbersdorf  is  distin- 
guished by  its  excellent  climate  during  summer,  which  is  not 
hot,  but  cool,  almost  without  rains,  and  is  protected  from  noxious 
winds  ;  in  connection  with  this  the  air  is  remarkably  pure,  free 


—  305  — 

from  dust  and  rich  in  ozone,  thanks  to  the  abundance  of  trees, 
especially  of  firs :  it  abounds  therefore  in  many  pleasant,  shady 
walks  ;  the  soil  is  hard. 

Brehmer  was  convinced  of  both  the  "  immunity"  of  mountain- 
ous localities  as  regards  tuberculosis  and  of  the  beneficial  influ- 
ence of  the  rarefied  air  of  the  mountains  on  tuberculous  pa- 
tients, although  the  environs  of  Gorbersdorf  present  cases  of 
consumption ;  and  as  regards  the  rarefaction  of  the  air  —  not 
to  repeat  what  was  said  before,  that  there  was  no  foundation 
for  ascribing  to  it  any  special  benefit  for  the  consumptives  — 
we  can  not  speak  of  the  presence  of  any  considerable  rarefaction 
of  the  air  on  such  but  slightly  elevated  locality  as  Gorbersdorf. 
Besides  that,  Brehmer  entertained  a  theory  of  his  own  regard- 
ing the  beneficial  influence  of  mountainous  localities  on  tuber- 
culous patients,  namely:  tuberculosis  attacks  persons  whose 
lungs  are  large,  but  whose  hearts  are  of  small  dimensions,  and 
in  whom  therefore  the  lungs  are  not  sufficiently  supplied  with 
blood  and  are  poorly  nourished,  and  who  through  such  conditions 
become  predisposed  to  tuberculous  affections ;  on  the  mountains 
the  pulse  becomes  more  frequent,  which  means  that  the  activity 
of  the  heart  is  increased,  the  lungs  receive  a  greater  supply  of 
blood,  they  are  better  nourished,  and  therefore  are  better  able 
to  withstand  tuberculosis  and  can  sooner  be  cured  of  it.  This 
theory  was  of  course  proved  to  be  without  any  patho logo-anatom- 
ical foundation  in  fact,  not  to  speak  of  the  insignificant  influ- 
ence of  such  a  slightly  elevated  locality  as  Gorbersdorf  on 
the  increase  of  the  frequency  of  the  pulse. 

But  all  this  notwithstanding,  Brehmer  achieved  a  greater  suc- 
cess in  the  treatment  of  patients  afflicted  with  chronic  pulmonary 
tuberculosis,  than  was  obtained  by  the  ordinary,  at  that  time, 
treatment  of  such  patients.  This  fact  was  recognized  by  com- 
petent German  physicians  and  clinicists  and  has  led  to  the  es- 
tablishment of  sanatoria  after  that  of  Gorbersdorf,  with  the 
application  of  Brehmer's  method  of  treatment.  This  "  method 
of  treatment,"  to  which  Brehmer  is  so  much  indebted  for  his 
successes,  consists  properly  speaking  of  a  strict  observance  of 
hygiene.  Thus,  in  the  other  climatic  sanatoria  patients,  under 
the  impression  that  the  climate  will  do  everything  and  that  every- 


—  306  — 

thing  is  possible  in  such  a  climate,  neglected  the  necessaiy  hy- 
giene as  much  as  they  did  in  their  own  homes,  permitted  them- 
selves to  smoke,  to  drink  too  much  wine,  did  not  observe  the 
diet  regularly,  spent  the  nights  in  playing  cards,  in  visitmg 
the  theatre,  etc.,  and  therefore  took  no  advantage  of  the  pleasant 
hours  during  the  day  while  the  sun  is  up,  nor  of  the  fresh  air 
and  out-door  exercises.  Brehmer  was  remorseless  in  requiring 
of  his  patients  the  strictest  observance  of  hygiene ;  he  insisted 
upon  the  avoidance  of  pernicious  habits  in  the  mode  of  living, 
upon  going  to  bed  in  due  time,  upon  as  prolonged  out-door  life 
as  possible,  upon  exercise  compatible  with  the  patient's  strength  ; 
he  required  a  correct  diet  (in  the  form  of  frequent  administra- 
tion of .  nutritious  food)  and  the  use  of  wine  ;  and,  besides  all 
these,  he  ventured  to  introduce  hydrotherapy  into  the  treatment 
of  tuberculous  patients.  It  is  true,  that  both  the  use  of  wine  and 
the  application  of  hydrotherapy  w^ere  conducted  without  a  plan 
and  with  too  great  impulsiveness  (thus,  for  instance,  the  patients 
were  given  too  strong  douches)  and  at  times  they  were  produc- 
tive of  harm  ;  but  it  was  nevertheless  shown,  that  wine  and  such 
moderate  hydrotherapeutic  procedures  as  sponging,  when  not 
prescribed  aimlessly  but  by  observing  the  individual  peculiari- 
ties of  every  patient,  are  of  benefit  to  many  suffering  with 
chronic  pulmonary  tuberculosis. 

Of  the  various  sanatoria,  which  were  established  in  imitation  of 
that  at  Gorbersdorf,  we  must  stop  to  consider  the  one  best  known 
of  all,  namely,  Davos  in  Switzerland.  Davos  is  a  wide  tableland 
situated  at  an  altitude  of  1960  meters,  protected  by  mountains 
from  northerly  and  northwesterly  winds.  The  best  season  of  the 
year  is  the  advanced  winter,  when  the  covering  of  snow  is  constant, 
the  air  is  pure  when  there  is  no  wind,  the  sky  is  almost  always 
clear  and  the  sun  sends  down  sufficient  warmth ;  thanks  to  this, 
as  well  as  to  the  dryness  and  the  quietude  in  the  air,  it  is  so  warm 
that  the  patients  are  able  to  be  up  and  about  out-of-doors 
in  comparatively  light  garments.  During  the  other  seasons 
of  the  year  there  arrive  the  unpleasant  local  wmds  from  the 
mountains  and  plains  and  then,  in  the  autumn,  when  the  snow 
begins  to  fall,  and  in  the  spring  when  it  thaws,  the  climate  is 
damp  and  inconstant ;  and  the  summer  is  warm,  there  is  but  lit- 


—  307  — 

tie  shade,  and  it  is  dusty.  The  cHmate  of  Gorbersdorf  is  there- 
fore better  during  the  summer,  but  there  the  winter  is  worse, 
because  during  it  the  weather  is  often  damp  and  changeable. 
The  majority  of  other  European  health-resorts,  established  on 
the  plan  of  that  at  Gorbersdorf,  have  not  the  same  distinctly 
mountainous  character  as  Davos  has,  and  resemble  in  this 
respect  Gorbersdorf. 

Many  physicians  when  comparing  Davos  with  the  warm  cli- 
matic places,  for  instance  with  those  on  the  Riviera,  give  the 
preference  to  Davos  for  the  following  reasons  :  the  air  at  Davos, 
thanks  to  the  snow-covered  ground,  is  so  pure  that  it  stands  in 
this  respect  above  comparison  with  the  air  at  the  above-named 
warm  places ;  at  Davos  there  is  no  wind  during  the  winter  and 
the  climate  is  therefore  more  constant  than  in  the  warm  locali- 
ties where  noxious  wmds  prevail;  in  these  places  the  winter  is 
not  only  warm,  but  even  hot,  whereas  at  Davos  it  is  just  warm 
enough  to  enable  one  to  be  up  and  about  dressed  lightly :  thanks 
to  this  the  appetite  of  the  patients  living  at  Davos  is  better  than 
in  those  living  at  the  above-named  warmer  sanatoria. 

From  the  above  you  can  clearly  perceive  what  an  important 
change  took  place  during  the  last  decades  in  the  climatic  treat- 
ment of  chronic  pulmonary  tuberculosis :  whereas  formerly  the 
salvation  of  the  patients  living  in  the  middle  and  the  northern 
parts  of  Europe  and  generally  in  countries  with  a  similar  cli- 
mate, was  considered  to  lie  in  a  trip  to  the  South  and  a  prolonged 
residence  there  during  the  cold  season  of  the  year,  —  a  trip 
which  was  often  beset  with  difficulties  and  entailed  hardships 
on  the  patients  and  their  families,  which  was  frequently  attend- 
ed with  the  risk  of  a  failure,  and  often  impossible  for  many, — 
at  the^  present  time  such  patients  are  enabled  to  apply  the  cli- 
matic therapy  during  the  winter  season  much  nearer  to  their 
own  homes. 

There  is  also  a  possibility  for  this  treatment  with  us,  not 
only  in  our  mountainous  localities,  but  also  in  the  plains  so 
largely  prevalent  in  Russia.  The  slight  relief  of  the  soil  in  the 
form  of  a  forest,  especially  of  fir-trees,  serves  as  a  sufficient 
protection  from  cold  winds  and  exerts  a  modifying  influence  on 
the  winter  cold,  if  we   desire  to  select  a  place  which  is  located 


—  308  — 

on  the  inolines  of  the  soil  facing  the  south.  The  cover  of  snow 
insures  pure  air.  If  during  the  winter,  in  the  severe  colds,  the 
patients  will  be  compelled  to  confine  themselves  within  the 
house  for  a  longer  time  than  in  Western  Europe,  then  during 
the  autumn  and  spring,  when  we  have  yet  some  frost,  while 
there  it  is  already  thawing  and  damp  weather,  the  condition 
of  things  will  be  reversed.  If,  finally,  on  account  of  the  severity 
of  our  climate  its  influence  during  winter  will  be  inferior  to 
that  of  Western  Europe  (and  this  I  question  !  ),  then  how  many 
times  will  this  disadvantage  be  outweighed  by  the  possibility  of 
avoiding  the  above  alluded  to  difficulties  and  risks,  which  are 
inseparable  from  far  journej^s  and  prolonged  sojourn  in  remote 
countries  ;  it  will  remove  the  necessity  for  expenses  permitted 
but  to  a  few  and  frequently  bringing  ruin  to  the  welfare  of 
many  families,  necessitating  separation  from  the  familiar  sur- 
rounding circumstances  and  business  on  the  one  hand,  and 
compulsory,  oppressive  idleness  in  a  strange  land  on  the  other 
hand. 

Unfortunately  with  us  it  is  as  yet  an  affair  of  the  future. 
Up  to  now  there  prevail  though  to  a  slighter  extent  than  for- 
merly, advices  for  trips  to  "  the  South  "  and  "  over  the  border  " 
(meaning  Western  Europe).  Many  physicians  prefer  the  ready 
advice  "  Take  a  trip  to  Cannes,  Mentone,  San  Remo,  etc.,  or  to 
Gorbersdorf,  Davos,"  to  the  one  which  requires  more  labor  to 
explain  as  to  how  the  patient  should  conduct  himself  in  the  cli- 
matic circumstances  which  surround  him  or,  in  case  these  be 
unsatisfactory,  how  to  take  advantage  of  those  near  by,  frequent- 
ly of  the  very  near  and  directly  neighboring  localities  with  fa- 
vorable climatic  conditions.  Besides,  it  frequently  happens  that 
the  advice  to  go  to  the  South  or  to  Europe  is  given  with  such 
abruptness  and  so  negligently,  that  the  patient  decides  to  under- 
go the  necessary  expenses  for  the  trip,  under  the  impression 
that  the  trip  itself  will  bring  about  a  cure  ;  he  perceives  later 
on,  that  the  trip  failed  to  cure  (it  frequently  does  not  even 
bring  about  an  improvement  in  health),  and  that  not  only  a  cure 
but  even  a  satisfactory  improvement  in  health  requires  a  long 
time,  treatment,  and  a  constant  observance  of  hygiene  ;  having 
given  up  the  trips  which  became  impossible,his  means  and  affairs 


—  309  — 

ruined,  he  ends  by  what  the  physician  should  have  advised  him 
to  begin,  namely  by  attempting  to  improve  his  health  not 
through  temporary,  fruitless  measures,  as  trips  to  the  south, 
but  by  changing  his  mode  of  living  in  accord  with  the  conditions 
of  his  health  and  by  taking  ably  advantage  of  the  climatic  op- 
portunities presented  by  the  local  place  of  residence  or  by 
the  one  nearest  to  it. 

A  few  cases  from  my  practice  will  serve  as  illustrations  of 
what  I  said. 

1.  This  case,  which  I  observed  some  twenty-five  years  ago, 
has  remained  indelibly  in  my  mind,  as  it  produced  a  strong 
impression,  and  has  been  the  means  of  my  inaugurating  the 
present  practice  in  the  domain  of  climatic  therapy.  The  pa- 
tient, forty  years  old,  of  average  constitution,  sober  and  non- 
syphilitic,  was  a  grain  merchant  on  the  Moscow  baggage 
station  of  the  Moscow  Ryazan  Railroad.  He  passed  the  whole 
day  either  in  talking  (usually  loudly,  rapidly,  without  rest,  and  fre- 
quently also  shouting)  out  in  the  dusty  or  cold  air,  or  in  drink- 
ing tea  in  the  tavern.  When  I  saw  the  patient,  he  had  been 
suffering  already  for  about  a  year  and  a  half  from  chronic  pul- 
monary tuberculosis  of  the  right  lung  (approximately  the 
upper  third  of  the  superior  lobe  was  attacked),  had  frequently 
expectorated  blood,  was  often  feverish,  grew  thin,  but  was  as 
yet  strong. 

After  having  removed  by  symptomatic  treatment  (leeches 
to  the  coccyx,  quinme,  pulvis  Doveri)  the  acute  condition 
for  which  the  patieut  consulted  me,  I  made  it  clear  to  him 
that  a  satisfactory  improvement  of  his  health  is  impossible 
with  his  present  mode  of  living,  and  inquired  whether  he 
would"  be  able  to  take  a  trip  to  the  South  (it  was  during 
winter  then),  warning  him,  however,  that  there  might  arise  a 
necessity  for  more  than  one  trip.  Patient  replied  that  neither 
his  competency  nor  his  family  relations  permitted  him  to  even 
attempt  such  a  thing.  Further  inquiries  elicited  the  fact, 
that  he  had  iu  his  possession,  some  200  miles  to  the  south- 
east of  Moscow,  a  pleasant  country  place  which  is  neither 
dusty  nor  damp,  and  a  fair  little  house ;  some  vegetation,  vari- 
ous household  buildings  and  a  barn  could  form  a  distinct  pro- 


—  310  — 

tection  from  the  winds ;  it  was  also  found  that  the  patient 
could  give  up  liis  present  occupation,  and  having  settled  down 
in  his  country  place,  would  be  able  to  find  also  some  occupa- 
tion there. 

Having  prescribed  for  the  patient  treatment  with  cod-liver 
oil  (we  did  not,  at  those  times,  give  creosote  in  large  doses) 
and  the  drinking,  in  the  morning,  of  Obersalzbrunnen  with 
milk,  and  having  instructed  him  as  to  what  he  was  to  do  in 
case  of  the  appearance  of  fever  and  the  mcrease  of  the  cough, 
I  positively  advised  him  to  leave  Moscow  and  to  move  to 
the  country  place,  explaining  to  him  the  hj^giene  in  particu- 
lar: to  permit  a  temperature  in  the  room  which  should  not 
be  hot,  to  have  a  warm  water-closet,  to  use  but  lukewarm  and 
no  hot  drinks,  to  replace  the  greater  part  of  tea  by  milk ;  nor 
must  his  food  be  hot;  to  take  a  bath,  not  a  hot  one,  during  the 
warm  season  of  the  year  only,  and  that  not  frequently ;  during 
the  cold  season  to  sponge  the  body  with  a  mixture  of  warm 
water  and  brandy;  but  the  chief  thing  —  not  to  go  out-of- 
doors  during  severe  frosts,  when  the  wmd  is  cold  and  when 
there  is  no  protection  against  its  blasts,  or  when  the  air  is  very 
damp,  or  occasionally  dusty;  and  on  the  other  hand  to  take 
advantage  at  any  time  of  staying  out-of-doors,  when  the  frost  is 
not  severe,  say  between  eight  or  ten  degrees  (patient  was  always 
habituated  to  cold),  when  the  weather  is  quiet  and  protection 
against  the  wind  may  be  obtained  along  the  various  country 
buildings  and  around  the  garden  or  the  grove,  when  the  air 
is  neither  damp,  nor  dusty ;  not  to  talk  during  the  cold  season 
of  the  year  while  out-of-doors,  and  generally  to  talk  only  as 
much  as  necessary,  not  loudly,  and  drawing  the  breath  care- 
fully ;  finally,  to  devote  himself  to  some  occupation,  but  not 
to  work  beyond  his  strength,  never  permitting  himself  to 
become  fatigued. 

The  patient,  being  an  intelligent,  careful  man  with  a  strong 
will  power,  followed  my  advice  to  the  letter  and  appeared  be- 
fore me  a  year  later  (during  May  of  the  next  year),  aston- 
ishing me  by  such  a  marked  improvement  in  his  health  than 
which  I  saw  no  greater,  not  only  from  one  winter's  sojourn,  but 
from  that  of  several  winters  spent  by  such  patients  in  the  South  : 


—  311  — 

the  nutrition  was  completely  improved,  he  gathered  considerable 
strength,  there  was  no  haemoptysis;  fever  and  aggravation 
of  the  cough  occurred  but  at  rare  intervals,  incomparably  less 
frequently  than  before,  the  cough  in  general  and  the  quantity 
of  expectoration  diminished,  the  dullness  at  the  area  of  the  af- 
fected place  changed  but  little,  but  the  area  over  which  rales 
had  been  heard  decreased  considerably.  I  must  add  that 
the  patient  did  not  give  up  his  accustomed  occupation,  and  not 
more  than  during  fifty  days  was  he  compelled  to  confine  him- 
self within  the  house,  partly  on  account  of  the  weather,  partly 
because  of  the  fever  and  the  aggravated  cough.  During  the 
next  seven  or  eight  years,  he  showed  himself  to  me  at  first 
every  year,  and  then  every  other  year,  usually  in  May,  always 
in  the  same  good  condition  as  after  the  first  year  of  his  country 
life.  The  further  condition  of  the  patient  is  not  known  to  me ; 
but  whoever  is  familiar  with  the  miserable  results  generally 
brought  about  by  the  trips  to  various  health-resorts,  trips  which 
require  constant  moving  around,  from  the  home  to  the  sanato- 
rium and  back,  and  which  cause  so  much  ruin  to  the  family, 
to  the  affairs  and  to  the  well-being  of  the  patient  —  whoever 
knows  all  this  will  certainly  perceive  the  impression  produced 
on  my  mind  by  the  above-described  results  of  the  climatic  treat- 
ment (or  to  be  more  precise,  by  the  generally  hygienic  treatment) 
at  one^s  ovjn  home. 

Let  me  tell  you  of  some  cases,  peculiar  in  another  respect, 
observed  in  my  recent  practice. 

2.  In  July  of  last  year  I  was  called  to  see  the  wife  of  a  country 
merchant,  thirty-one  years  old,  who  complained  of  eough,  dysp- 
noea, emaciation  and  general  weakness,  and  who  desired  me  to 
inform  her  as  to  whether  or  not  she  should  go  to  Yalta  (in  the 
Crimea),  as  advised  by  her  physicians. 

The  locality  where  the  patient  resides '(in  the  Tula  Govern- 
ment) is  a  poor  one,  and  except  wmter-time  it  is  either  dusty  or 
muddy.  The  residence  is  satisfactory,  the  water-closet  cold. 
The  board  is  good,  her  beverage  consists  of  hot  tea  with  milk, 
no  alcoholic  drinks.  Patient  has  been  married  for  twelve  years, 
has  nursed  in  all  eight  children,  of  whom  five  are  alive.  No  syph- 
ilis.    Notwithstanding  the  frequent  births,  the  nursing  of  the 


—  312  — 

children  and  a  considerable  amount  of  housework,  the  patient 
assists  also  her  husband,  spending  daily  some  five  hours  in  a 
cold  flour-store,  situated  on  a  dusty  street.  Patient  is  very 
much  attached  to  the  children  and  the  family,  and  is  a  typical 
specimen  of  a  good  wife  and  mother,  and  of  a  verj^  painstaking 
housekeeper. 

Until  five  years  ago  she  had  enjoyed  good  health.  Five 
years  ago  during  autumn  patient  passed  through  an  attack  of 
pleurisy  (severe  pains  in  the  left  side  of  the  chest,  cough,  fever ; 
the  principal  treatment  consisted  in  the  application  of  Spanish 
flies,  which  relieved  her),  after  which  she  began  to  cough,  at 
first  but  little,  and  later  on  more  and  more,  and  became  also 
feverish ;  but  of  this  she  took  no  notice  and  continued  to  work 
as  usual.  Two  months  ago  the  patient  began  to  feel  very  ill 
and  took  to  bed:  there  appeared  severe  pains  in  the  left  side 
and  a  considerable  fever,  while  the  formerly  moderate  cough  be- 
came aggravated  and  the  expectoration  began  to  show  the  pres- 
ence of  blood.  In  the  course  of  three  weeks  the  fever  decreased, 
but  the  severe  cough,  the  abundant  expectoration  and  the 
dyspnoea  remained  until  now,  and  the  patient  continues  to  ema- 
ciate and  weaken.  Her  treatment  consisted  m  the  application 
of  flies,  and  during  two  weeks,  until  the  middle  of  June,  she 
has  been  taking  six  drops  of  creosote  daily ;  later  on,  at  the  be- 
ginning of  July,  patient  was  advised  to  take  a  trip  to  Yalta. 

Status.  —  Her  appetite  is  poor ;  dyspeptic  phenomena  absent ; 
she  is  constipated  (patient  takes  two  or  three  times  during  the 
week,  thirty  or  more  drops  of  extr.  fluid,  cascarse  sagradse). 
The  urine  contams  a  small  quantity  of  albumen  and  a  few  hy- 
aline cylinders.  Menstruation  is  regular,  of  normal  quantity  and 
painless.  The  liver  and  the  spleen  are  normal ;  so  is  the  heart, 
but  the  pulse  is  frequent  and  weak.  There  is  some  dys- 
pnoea, cough,  expectoration  of  about  two  tablespoonfuls  a  day, 
at  times  with  an  admixture  of  blood ;  coughmg  causes  pain  in 
the  left  side  of  the  chest.  On  the  lower  half  of  the  left  side  of 
the  chest,  posteriorly  and  laterally,  there  is  dullness  on  per- 
cussion, while  auscultation  elicits  bronchial  respiratory  murmur 
and  some  rales ;  the  apex  of  the  left  lung  shows  a  characteristic 
focus  with  abundant  and  loud  moist  rales  ;  objective  examination 


—  313  — 

of  the  right  side  gives  normal  data.  The  patient  is  somewhat 
feverish,  her  sleep  is  sound,  and  not  interrupted  by  the  cough, 
the  head  aches  when  the  fever  is  increased. 

The  patient  and  her  husband  stated  to  me  that  the  advice  to 
take  a  trip  to  Yalta  causes  them  a  great  deal  of  anxiety ;  that 
such  a  trip  was  for  them,  plain  country  people,  a  matter  of  un- 
usual importance,  as  it  might  possibly  result  in  many  unpleas- 
ant accidents ;  that  it  was  impossible  for  the  husband  to  accom- 
pany his  wife,  and,  which  is  most  important  of  all,  she 
would  be  unable  to  take  along  the  children,  all  of  whom  were 
very  young  as  yet;  that  the  mother  was  so  attached  to  them, 
and  they  to  her,  that  separation  would  be  intolerably  painful 
and  harmful  for  the  mother's  health.  The  husband  told  me 
that  the  wife  having  gone  without  the  children  to  live  in  a 
country  place,  she  could  not  stand  the  separation  but  for  two 
days  and  was  compelled  to  return,  while  the  "  children  were 
crying  all  the  time  during  her  absence."  Further  inquiry  elicit- 
ed the  fact  that  the  husband  possessed,  some  four  or  five  miles 
from  his  constant  residence,  a  section  of  forest  in  a  pleasant,  dry 
locality,  and  that  he  had  built  there  a  spacious  and  clean  little 
house  in  a  place  completely  protected  from  wind  and  dust. 

My  advice  was  as  follows  :  I  could  not  approve  of  a  residence 
of  two  months'  duration  at  Yalta ;  on  the  contrary  I  feared  the 
possible  heat,  so  harmful  for  the  appetite,  and  the  dust,  and  I 
advised  the  woman  to  remove  together  with  her  children  to  the 
above-named  country  place  and  to  remain  there  until  the  appear- 
ance of  snow,  when  she  might  return  to  her  constant  residence. 
I  explained  to  the  patient  and  to  her  husband  that  it  was  not 
only  necessary  for  her  to  recover  from  the  disease  which  attacked 
her  two  months  ago,  namely,  inflammation  of  the  left  lung,  but 
also  to  get  rid  of  the  other  affection,  which  has  been  ruining 
her  health  during  the  last  five  years  and  which  settled  also  in 
the  same  lung  (tuberculosis  of  its  apex)  ;  I  made  it  clear  to 
them  that  she  must  therefore  remain  at  the  place  of  her  con- 
stant residence  only  during  the  winter,  when  thanks  to  the 
snow  and  frost  both  dust  and  dampness  are  absent,  while  the 
rest  of  the  time  she  is  to  live  in  the  above-named  country  place, 
where  a  more  spacious  residence  is   to  be  built  at  once,  with 


^  314  — 

conveniences  for  winter,  with  good  stoves,  and  chiefly  with 
double  floors  and  double  frames.  The  husband  replied  at 
once  that  he  could  do  all  this  very  readily,  that  by  autumn 
the  house  would  be  ready  for  occupancy.  To  this  I 
added,  of  course,  that  the  patient  must  take  care  of  herself, 
must  refrain  from  fatiguing  labor,  must  drink  more  milk  and 
less  hot  tea,  and  must  wear  drawers  (which  she  did  not  do 
before  and  which  were  required  in  view  of  a  possible  nephritis)  ; 
as  what  concerns  her  outdoor  life,  I  repeated  to  her  my  instruc- 
tions as  given  to  the  case  described  above.  I  further  instructed 
her  to  resort  to  the  use  of  clysters  in  case  of  constipation,  and 
to  take  a  laxative  only  in  case  the  clyster  proves  ineffectual ;  for 
the  cough  to  drink  Obersalzbrunnen  with  milk ;  to  take  guaiacol 
in  the  order  explained  in  the  treatment  of  chronic  pulmonary 
tuberculosis,  not  exceeding  the  dose  of  twenty  to  twenty-five 
drops  per  day  (because  of  the  albuminuria,  even  though  it  be 
trifling)  ;  in  case  of  weakness  to  take  the  stimulating  drops  (tra. 
valer.  seth.  and  liqu.  Anod.  Hoffm.  aa). 

3.  At  the  beginning  of  last  autumn  a  land  proprietress  in  one 
of  the  country  places  around  Moscow  requested  of  me  ad- 
vice about  her  daughter.  The  girl,  twelve  years  old,  of  a  weak- 
ly constitution  and  slightly  hysterical,  passed  a  year  ago  through 
a  severe  febrile  affection,  which  left  her  with  a  cough  and  debili- 
tated. The  family  physician  found  tuberculous  bacilli  in  the 
sputum  and  advised  Mentone  for  the  winter.  The  first  two 
months'  residence  at  Mentone  exerted  no  influence  on  her  health, 
and  only  after  she  commenced  taking  creosote  did  her  health  be- 
gin to  improve  markedly.  On  her  return  to  Russia  in  the  spring 
the  improvement  continued  (the  treatment  with  creosote  was 
discontinued  by  this  time),  and  by  autumn  only  the  cough  re- 
mained, without  any  expectoration. 

Status.  —  The  appetite  is  excellent,  the  digestion  normal,  all 
the  abdominal  organs,  as  well  as  the  heart  and  the  circulation, 
are  in  good  condition,  the  nutrition,  sleep  and  strength  good. 
Outside  of  a  moderate  dry  cough  the  organs  of  respiration  pre- 
sent nothmg  abnormal :  objective  examination  fails  to  elicit  any 
dyspnoea,  pains  or  any  other  pathological  changes.  The  physicians 
have  however  again  advised  her  to  go  to  Mentone  for  the  winter. 


—  315  — 

The  girl's  mother  declared,  that  in  view  of  the  large  family,  of 
her  husband's  affairs  and  the  serious  pecuniary  expenses 
incurred  b}^  such  a  trip,  this  last  presents  extremely  embarrassing 
diificulties  ;  that  the  improvement  m  the  girl's  health  began  not 
from  the  time  they  took  up  their  residence  at  Mentone,  but  only 
two  montlis  later,  when  she  began  the  creosote  treatment ;  that 
Mentone  is  crowded  and  dusty,  and  that  the  whole  family,  re- 
moved forcibly  from  the  habitual  conditions  and  cu'cumstances 
of  life  (they  always  led  a  country  life  in  a  healthy  locality, 
in  an  excellently  arranged  country  residence,  protected  from  the 
winds  by  the  woods)  felt  as  if  they  had  been  exiled.  I  told 
them  that  I  considered  the  life  at  ^lentone  as  unsuitable  for 
such  a  family,  and  that  m  m}^  opmion  the  trip  to  Mentone 
and  back  with  all  the  possible  accidents  attached  thereto,  as 
well  as  the  patient's  attempt  to  disaccustom  herself  from  a  cli- 
mate in  which  she  will  after  all  have  to  live,  were  much 
more  risky  than  to  remain  over  winter  at  home,  in  the 
accustomed,  favorable  place  of  residence ;  I  therefore  ad- 
vised to  constantly  remain  in  the  latter,  keeping  the  same 
points  in  view  —  mutatis  mutandis  —  as  explained  b}'  me  in  the 
foregoing  cases.  As  the  girl  was  formerly  studying  hard,  and 
had  at  times  to  pass  examinations,  which  circumstance  acted 
deleteriously  on  her  nervous  system,  and  being  of  a  lively  dis- 
position she  talked  a  great  deal  while,  out-of-doors,  I  advised 
to  entirely  give  up  the  examinations  conducted  m  the  manner 
harmful  for  the  nervous  system,  to  study  without  unnecessary 
effort,  to  talk  less,  and  to  strictly  refrain  from  talking  when  out- 
of-doors  during  cold  weather.  As  for  treatment  I  prescribed 
creosote. 

The  above  described  cases  may  serve  as  examples  of  my  hab- 
itual climatotherapeutic  practice.  The  results  of  such  practice 
as  regards  the  lasting  recovery  of  health  are  incomparably  better, 
in  my  observation,  than  the  results  obtained  by  frequent  trips 
to  far-away  places  with  a  totally  different  climate,  and  by  a  pro- 
longed sojourn  there.  I  will  not  speak  of  the  cares  and  worries 
that  one  avoids  in  the  treatment  at  home,  without  these  trips. 
It  would  however  be  narrow-mindedness  to  completely  deny  the 
benefit   derived  from  trips   with    climatic    treatment    in    view. 


—  316  — 

Each  given  case  must  be  individualized,  as  should  always  be 
■  done  in  therapy  :  if  in  the  majority  of  cases  such  trips  are  con- 
nected with  considerable  inconvenience  and  frequently  even 
with  serious  disturbances,  there  are  on  the  other  hand  eases 
where  all  these  are  absent,  where  on  the  contrary  it  becomes 
beneficial  for  the  patient,  not  only  for  climatotherapeutic  pur- 
poses, but  also  otherwise,  to  be  removed  away  from  various  un- 
favorable conditions  surrounding  him,  and  from  his  habitual 
mode  of  living.  But  it  may  be  stated  in  a  general  way,  that  a 
trip  with  climatic  treatment  in  view  is  particularly  indicated  in 
those  cases,  in  which  a  single  trip  and  but  a  short  sojourn  maj^ 
achieve  the  purpose  of  brmging  about  a  recovery  of  health,  as, 
for  instance,  in  cases  of  debility  after  an  attack  of  a  severe 
disease.  I  had  already  once  occasion  to  mention  the  indications  for 
such  a  trip  while  analyzing  our  first  case.  (Vide  the  lecture  of 
October  18,  1889,  at  the  end.)  But  in  cases  of  chronic  diseases, 
principally  in  chronic  pulmonary  tuberculosis,  in  which  lasting 
improvement  in  and  preservation  of  health  requires  not  only  a 
prolonged,  but  a  constant  residence  among  favorable  climatic  and 
generally  hygienic  surroundings,  a  trip  to  a  far-away,  the  more 
so  to  a  foreign,  land  is  indicated  only  at  the  beginning,  when  it 
becomes  necessary  to  at  once  put  the  patient  into  favorable  cli- 
matic conditions,  and  when  such  are  not  easily  found  at  home ; 
but  later  on  it  is  necessary  to  search  for  such  conditions  in  the 
place  of  residence  or  near  by,  at  any  rate  in  the  native  land,  in 
one's  fatherland,  where  the  patient  is  after  all  enabled  to  have 
some  occupation  proportionate  to  his  strength  (patients  with 
chronic  pulmonary  tuberculosis  are  entirely  incapable  of  any 
activity  only  in  the  last,  phthisical  stage),  which  would  to  some 
extent  satisfy  him  and  give  him  means  for  a  livelihood,  which  is 
very  rarely  possible  m  a  foreign  land. 


We  have  discussed  at  sufficient  length  the  general  hygiene  of 
patients  with  chronic  pulmonary  tuberculosis  several  times  be- 
fore, and  also  while  discussing  the  therapy  of  this  disease. 


TWENTY-SECOND  CASE. 


LECTURE  OF  MARCH  3,   J  893. 

Patient,  a  peasant,  nineteen  years  old,  was  admitted  to  the 
clinic  March  1st,  complaining  of  severe  dyspnoea,  of  pain  in  the 
left  side  of  the  chest,  of  headache  and  general  weakness. 

Mode  of  living  and  anamnesis.  —  For  the  last  five  years  pa- 
tient has  lived  at  Moscow.  His  rooms  are  dry  and  warm,  but 
being  a  clerk  in  a  green-grocer's  shop,  he  spends  his  whole  day 
in  a  basement  floor  where  the  store  is  located.  Bathes  himself 
at  times  during  the  summer,  takes  a  hot  bath  once  in  two  weeks, 
drinks  a  sufficient  quantity  of  tea,  but  no  brandy  ;  does  not 
smoke.  His  board  is  that  of  a  workingman.  Patient  is  single, 
never  had  any  venereal  diseases. 

Patient  comes  from  a  healthy  family ;  he  had  smallpox  dur- 
ing childhood,  but  since  then  up  to  the  present  illness  enjoyed 
good  health.  February  the  27th  he  remained  for  a  long  time 
in  an  ice-cellar,  was  thoroughly  chilled  and  m  the  evening  felt  a 
pain  in  the  left  side,  had  a  severe  chill  and  later  fever  which 
continued  up  to  the  time  he  entered  the  clinic,  March  1st. 
On  the  day  of  his  admission  patient  was  given  twelve  one- 
grain  powders  of  calomel,  one  every  hour  (before  that  he  did 
not  move  his  bowels  for  two  days).  He  had  four  abundant 
characteristic  calomel  evacuations,  attended  with  slight  pain  :  he 
was  then  given  five  drops  of  tra.  opii  and  his  abdomen  was 
wrapped  in  some  flannel ;  after  this  the  mtestinal  pains  quieted 
down  and  the  loosenesss  of  the  bowels  ceased.  He  was  given 
twice  a  day  twenty-five  stimulant  drops  (tra.  valer.  aether,  and 
liqu,  anod.  Hofmanni  aa)  and  the  left  side  of  the  chest  was  kept 
warm  by  rubbing  with  warm  oil,  and  then  wrapping  it  with 
cotton-wadding  and  flannel. 

Status.  —  Average  constitution.     He  has  no  appetite,  there 

317 


—  318  — 

are  no  dyspeptic  phenomena,  nor  were  there  any  previous  to  the 
disease.  Had  regular  stools  before  he  fell  sick ;  had  no  stool 
during  the  first  two  days  of  the  disease,  then  was  given  calomel, 
later  opium.  During  the  last  twenty-four  hours  he  had  one 
stool,  somewhat  liquid  but  without  pain.  The  urine  passes 
freely,  500  c.c.  during  the  twenty-four  hours,  is  rich  in  urates, 
contains  neither  sugar,  nor  albumen.  Tlie  abdomen,  as  well  as 
the  whole  body,  is  slightly  sensitive  to  pressure ;  there  is  a  hy- 
pergesthesia  cutis  in  connection  with  a  high  temperature.  The 
liver  and  spleen  are  normal.  The  heart,  except  for  the  fre- 
quency of  the  contractions  (pulse  100),  is  normal ;  the  pulse, 
which  was  somewhat  weak  on  admission,  is  now  good.  There  is 
some  dyspncea,  —  respiration  32,  on  admission  36  per  minute, — 
some  trifling  pain  in  the  left  side  of  the  chest,  a  slight  cough, 
with  some  tliick  viscid  expectoration  of  a  rusty  color.  There  is 
a  dull  percussion  sound  under  the  left  scapula,  bronchial  breath- 
ing and  vocal  fremitus  are  more  pronounced  than  under  the 
right  scapula.  Objective  examination  in  the  other  regions  of 
the  chest  elicits  nothing  abnormal.  Headache  and  dizziness 
on  getting  up.  His  sleep  is  fair.  There  is  general  debility. 
The  course  of  the  temperature :  the  morning  of  the  day  before 
yesterday,  on  admission,  40.2°  R.  (104.4°  i^.),  evening  (he 
had  before  this  some  calomel  stools),  39°  R.  (102.2°  1^.), 
yesterday  morning,  38.7°  R.  (101.6°  i^.),  in  the  evening, 
40°  R.  (104°  F.),  this  morning,  39.  5°  R.  (103.2°  F.~). 

Diagnosis.  —  Here,  as  in  the  case  of  the  pleurisy  with  effusion 
(nineteenth  case),  we  evidently  have  to  do  with  an  acute 
disease  in  the  cavity  of  the  chest  which  causes  a  febrile  con- 
dition, this  last  appearing  simultaneously  with  the  local 
symptoms,  namely  pains  in  the  left  side  of  the  chest.  This 
disease  may  be  either  pneumonia  or  pleurisy  with  effusion. 
If  we  review  the  comparison  between  the  symptoms  of  both 
diseases,  which  we  did  while  discussing  the  above  mentioned 
case,  we  shall  see  that  the  symptoms  of  the  present  case  speak 
against  pleurisy  with  effusion,  and  for  pneumonia,  namely,  for 
croupous  pneumonia  (fibrinous)  :  the  pains  in  the  side  are  not 
severe ;  together  with  a  dull  percussion  sound  there  is  observed 
clear  bronchial  respiration,  and  not  the  weak  respiratory  mur- 


—  319  — 

mur  of  indefinite  quality,  as  in  the  above-named  case  of  pleurisy 
with  effusion ;  the  vocal  fremitus  is  increased  (there  it  is  weak- 
ened), the  cough  is  not  dry,  as  it  is  there,  but  with  expectora- 
tion and  characteristic  at  that  of  fibrinous  pneumonia ;  the 
affection  of  the  lower  lobe  of  the  lung  is  also  characteristic  of 
the  same.  The  course  of  the  temperature,  when  it  became 
established  after  its  fall  caused  by  calomel  passed  away,  also 
speaks  for  pneumonia,  namely,  the  temperature  is  high,  and  the 
difference  between  the  morning  (to-day  39.5°  R.  — 103.2°  ^.)  and 
the  evening  (last  evening  40°  B.  — 104  FS)  is  trifling,  of  one-half 
of  a  degree,  whereas  in  the  above-named  case  of  pleurisy,  at  the 
beginning  of  the  patient's  stay  in  the  clinic  before  antipyretics 
had  been  prescribed  for  him,  the  morning  temperature  was  38.1 
R.  (100.6°  F.~),  that  of  the  evening  39.6°  R.  (103.2°  J^.).  The  mi- 
croscopical examination  of  the  sputum,  so  easy  of  accomplishment 
in  the  clinic,  but  difficult  in  private  practice,  is  unnecessary  in 
the  present  case,  as  the  diagnosis  is  evident  beyond  doubt.  It 
is  otherwise,  if  we  have  to  deal  with  a  pneumonia  in  the  upper 
pulmonary  lobe,  and  especially  in  a  patient  in  whom  we  are  led 
to  suspect  the  presence  of  tuberculosis :  then  it  is  certainly  neces- 
sary to  examine  the  expectoration  for  prognostic  as  well  as  ther- 
apeutic purposes  ;  it  ma}"  contain  in  one  case  tubercular  bacilli, 
in  another  pneumonic  diplococci,  and  in  a  thu'd  both. 

Prognosis.  —  The  case  is  serious ;  it  may  terminate  in  re- 
covery, but  may  also  end  m  death ;  which  of  the  two  it  is  im- 
possible to  say,  but  we  may  certainly  with  greater  probability 
hope  for  recovery,  in  view  of  the  patient's  youth,  his  fair  con- 
stitution and  the  good  condition  of  his  cardiac  activity,  and  also 
because  of  the  fact  that  during  the  two  days  that  the  patient 
has  been  in  the  clinic  we  did  not  observe  any  further  spread  of 
the  pneumonic  process.  In  addition  to  this,  the  patient  has  been 
placed  since  the  day  before  yesterday  into  favorable  conditions 
by  his  life  in  the  clinic,  and  is  subjected  to  treatment :  the 
calomel  lowered  the  temperature  considerably  for  more  than 
twenty-four  hours,  and  it  was  probably  the  cause  why  the  pneu- 
monia did  not  spread. 

Treatment.  —  We  possess  as  yet  no  specific  remedies  for  pneu- 


—  320  — 

monia,*  and  have  to  rely  on  the  symptomatic  treatment.  We  must 
combat  the  symptoms  of  the  disease,  and  prevent  any  of  them 
from  developing  to  any  dangerous  extent,  until  the  disease  will 
terminate  itself.  As  ordinarily  dangerous  symptoms  in  croupous 
pneumonia  may  be  considered  a  very  high  temperature,  a  very 
weakened  cardiac  activity,  and  dyspnoea  ;  the  cough  (and  very 
rarely  pain  in  the  side)  may  be  considered  not  as  a  directly 
dangerous,  but  as  a  very  embarrassmg  symptom  which  exerts 
a  harmful  influence  on  the  patient's  condition. 

I  prescribe  treatment  for  high  temperature  in  croupous 
pneumonia  only  when  I  see  that  its  effects  are  fraught  with 
danger.  As  a  measure  of  the  degree  of  danger  of  these  effects 
are  considered  the  patient's  sensations,  the  condition  of  the 
pulse  and  the  respiration:  the  higher  the  fever,  the  worse  the 
patient  feels,  and  the  worse  are  the  pulse  and  the  respiration, 
and  on  the  contrary,  so  that  with  the  fall  in  the  temperature 
and  with  the  termination  of  the  crisis,  the  patient  usually  feels 
well,  the  pulse  becomes  good,  or  yields  easily  to  the  effect  of 
cardiac  stimulants,  and  there  is  no  dyspnoea  even  by  the  time 
when  the  local  affection  presents  as  yet  no  changes  and  remains 
in  the  former  extent. 

The  worse  therefore  the  patient  feels,  as  evidenced  by  ex- 
treme anxiety  and  a  feeling  of  distress,  the  weaker  the  pulse 
and  the  greater  the  dyspncea,  the  more  necessary  does  it  be- 
come to  lower  the  temperature. 

I  have  long  ago  discarded  digitalis,!  cold  baths  and  quinine 
as  means  for  lowering  the  high  temperature  of  croupous  pneu- 
monia ;  quinme  I  give  only  in  the  very  last  stage  of  the  disease, 
when  resolution  is  prolonged,  and  when  the  febrile  condition 
is  of  a  strongly  remittent  nature  in  the  mornings.  I  also  give  it, 
as  described  above,  in  chronic  pulmonary  tuberculosis,  thus : 
for  the  morning  remission  qumine,  and  for  the  evening 
exacerbation    phenacetine    or   antifebrine ;    but    to    lower   the 

*  The  attempts  to  treat  croupous  pneumonia,  as  well  as  the  attempt  to 
create  immunity  towards  it,  by  the  products  of  the  life  activity  of  the  mi- 
cro-organisms considered  as  the  causative  agency  of  the  disease,  are  as 
yet  not  ripe  enough  for  practical  application. 

t  See  article  on  the  treatment  of  croupous  pneumonia  by  calomel. 


—  321  — 

temperatui-e  of  croupous  pneumonia  I  resort  to  calomel,  only 
in  patients  of  a  strong  constitution,  and  only  at  the  incipiency 
of  the  disease  when  the  strength  is  in  good  condition;  espe- 
cially do  I  give  it  when  there  is  an  indication  for  calomel 
as  evidenced  by  the  condition  of  the  gastro-intestinal  canal 
(as  constipation,  meteorism,  and  a  high  position  of  the  dia- 
phragm, tending  to  increase  the  dyspnoja),  and  by  that  of  the 
biliary  passages.  The  effect  of  calomel  in  croupous  pneumonia 
is  explained  in  the  article  alluded  to,  and  is  partly  also  seen 
from  the  present  case.  To  repeat  calomel  in  croupous  pneu- 
monia is  usually  unnecessary  in  view  of  the  short  duration 
of  the  disease  and  the  danger  of  weakening  the  patient.  To 
further  lower  the  temperature,  to  bring  it  down  from  an  im- 
desirable  elevation,  I  usually  give  phenacetine  or  antifebrine, 
ordinarily  in  the  evening  when  the  fever  is  increased,  and  in 
small  doses  (three  to  eight  grains  of  phenacetine,  or  three  to  five 
grains  of  antifebrine),  which  usually  prove  satisfactory.  I 
avoid  the  use  of  sodium  salycilate  and  of  antipyrine  in  view 
of  their  weakenmg  effect  on  the  heart,  which  effect  is  especially 
dangerous  in  pneumonia. 

To  keep  up  the  weakened  cardiac  activity  I  administer  the 
stimulating  drops  mentioned  here  more  than  once,  wine,  coffee 
with  cognac,  whiskey,  less  frequently  camphor  (to  persons 
not  habituated  to  alcohol  and  unable  to  bear  it). 

Treatment  of  dyspnoea^  pains  and  cough.  —  There  occur  in- 
frequent cases  in  which  the  dyspnoea  is  at  the  beginning  of 
the  disease  so  severe  that  it  requires  local  bloodlettmg,  less 
frequently  general ;  these  are  cases  presenting  a  tempestu- 
ous onset  of  croupous  pneumonia,  when  in  conjunction  with 
severe  pains  which  embarrass  respiration,  a  considerable  portion 
of  one  lung  becomes  suddenly  affected,  and  simultaneously 
with  this,  because  of  the  impeded  cii'culation  in  the  affected 
lung  and  of  the  weakened  cardiac  activity  (on  account  of  the 
very  high  temperature),  there  takes  place  an  oedema  of  the 
other  lung  which  develops  rapidly,  and  is  at  times  accompanied 
by  haemoptysis.*  But  ordinarily,  a  sufficient  relief  of  the 
dyspnoea  is  obtained   by  lowering   the    high   temperature,    by 

*  Vide  article  on  "Bloodletting." 


—  322  — 

strengthening  the  weakened  activity  of  the  heart,  and  by  re- 
lieving the  pains  and  the  cough.  In  case  the  dyspnoea  is  very 
severe  and  dangerous,  as  a  result  of  an  oedema  of  the  lungs 
developed  in  acute  cases  at  the  termination  of  the  croupous 
pneumonia,  —  in  a  patient,  already  debilitated  and  presenting 
symptoms  of  an  approaching  collapse,  —  then  bloodletting  is 
not  to  be  resorted  to  (as  recommended  by  many  text-books), 
as  it  is  then  a  very  risky  measure  under  such  conditions,  but 
stimulants  must  be  administered,  also  senega,  and  large  Spanish 
flies  are  applied. 

For  relieving  the  pain  it  is  usually  sufficient  to  keep  the 
pamful  side  of  the  chest  warm  (by  the  aid  of  warm  oil,  batting 
and  flannel),  to  relieve  the  cough,  and  the  coughing  spells 
which  tend  to  aggravate  the  pains.  It  is  only  on  rare  oc- 
casions that  we  have  to  resort  for  the  relief  of  the  pain  to 
local  bloodletting  or  to  an  hypodermatic  injection  of  morphium. 

As  the  cough  aggravates  the  pain,  and  through  this  as  well 
as  by  embarrassing  respiration  and  circulation,  it  also  aggravates 
the  dyspnoea,  and  prevents  sleep,  it  must,  therefore,  be  reduced 
to  the  possible  minimum.  As  long  as  the  expectoration  is 
scanty,  and  the  rales  are  either  few  or  entirely  absent,  we 
should  give  codeine,  opium,  in  the  form  of  pulvis  Doveri,  rarely 
morphine.  I  had  observed  many  times  that  the  first  thing 
a  physician  administers  to  a  patient  suffering  with  pneumonia, 
is  infusum  ipecacuanhse  which  is  continued  for  several  days  ; 
this  is  undoubtedly  an  error :  there  is  at  that  time  as  yet 
nothing  in  the  bronchi  that  can  be  brought  awa}^,  and  the 
ipecacuanha  only  tends  to  aggravate  the  cough,  and  if  ad- 
ministered for  a  long  time,  it  deranges  the  appetite  and  prevents 
its  timely  return.  On  the  other  hand,  we  must  exercise  ex- 
treme caution  during  the  administration  of  the  above-named 
narcotic  remedies.  Changes  in  the  course  of  croupous  pneu- 
monia are  liable  to  take  place  rapidly:  codeine,  opium  and 
morphine,  which  relieved  the  dry  cough,  and  therefore  also 
the  dyspnoea  and  the  pain,  thus  benefiting  the  patient  greatly 
until  say  the  fifth  or  sixth  day  of  the  disease,  may  become  harm- 
ful on  the  morning  of  the  following  day,  usually  at  the  time  during 
which  the  crisis  occurs,  by  aggravating  the  dyspnoea,  at  a  time, 


—  323  — 

when  the  respiratory  passages  are  filled  with  liquid  contents 
(as  evidenced  by  abundant  subcrepitant  and  more  prominent 
moist  rales,  whose  appearance  is  to  be  carefully  watched),  on 
account  of  the  entrance  mto  them  partly  of  the  liquefied  pneu- 
monic mfiltration  (although  this  is  usually  absorbed),  but  prin- 
cipally of  the  oedematous  fluid.  Now  we  must  put  aside  the 
above-named  narcotics,  which  we  gave  only  yesterday,  and 
while  continuing  the  stimulants,  we  resort  to  expectorants, 
usually  to  senega  in  an  infusion,  3j  -  3ij  to  fvj,  and  in  severe 
cases  also  to  large  Spanish  flies. 

We  will  now  turn  to  the  treatment  of  our  patient.  From 
the  data  outlined  above  you  will  perceive  that  there  are  no 
indications  at  present  for  bloodlettuig,  nor  were  there  any 
before.  The  indication  for  calomel,  as  well  as  its  effect  in  the 
given  case,  were  already  spoken  of.  What  shall  we  give  the 
patient  to-day  ?  We  will  first  of  all  give  him  agaiu  five  drops 
of  the  tincture  of  opium,  as  he  had  some  loose  stools,  although 
they  were  painless  and  appeared  once  during  the  twenty-four 
hours.  The  opium  will  also  be  beneficial  in  quieting  the 
cough.  We  will  contmue  the  stimulant  drops.  Their  action 
is  good :  twenty-five  drops  without  wine,  twice  a  day,  produce 
a  fair  pulse.  Pain  in  the  left  side  is  sufficiently  relieved  by 
the  part  being  kept  warm.  For  the  cough  —  tra,  opii,  and  in 
case  of  constipation,  one-fourth  grain  of  codeine.  As  the 
temperatiu'e  is  quite  high  and  the  dyspnoea  very  pronounced, 
we  will  give  him,  in  view  of  the  probable  evening  rise  of  the 
temperature,  three  grams  of  phenacetine. 


FROM  THE  LECTURE  OF  MARCH  5,   1893. 

The  day  before  yesterday,  at  seven  p.  3i.  the  temperature  was 
39.8°  R.  (103.6°  i^.),  and  after  he  took  three  grains  of  phenace- 
tine, it  fell  to  38.8°  R.  (101.8°  _^.)  by  ten  o'clock  in  the  evenmg  ; 
this  morning  it  is  39.5°  R.  (103.1°  i^.).  Yesterday  morning  the 
area  of  dullness  seems  to  have  spread  somewhat  upward,  to-day 
it  is  of  the  same  extent,  as  it  was  yesterday ;  there  is  no  further 
spread.  Auscultation  over  the  region  of  dullness  elicits  bron- 
chial breathing,  no  rales  anywhere.     The  pams  in  the  left  side, 


—  324  — 

as  also  the  cough,  are  trifling  and  cause  the  patient  no  incon- 
'  venience  ;  the  dyspnoea  is  moderate.  The  pulse  is  good ;  he 
gets  twenty-five  stimulating  drops  four  times  a  day.  He  is 
constipated.  The  sleep  is  fair,  he  feels  better,  the  hyperaes- 
thesia  cutis  disappeared. 

The  prognosis  remains  favorable,  because  all  the  symptoms 
are  slight,  the  strength  is  good,  and  at  the  present  time  there 
is  no  further  spread  of  the  pneumonia  ;  this  is  the  seventh 
day  of  the  disease  and  we  may  soon  expect  the  ci^isis. 

Treatment :  a  clyster,  coffee  with  milk  (as  a  cardiac  stimu- 
lant, at  the  same  time  counteracting  the  constipation),  stimu- 
lants, phenacetine  and  codeine,  as  necessity  requires;  finally, 
in  case  oedema  of  the  lung  supervenes  during  the  crisis, 
senega,  or  even  a  Spanish  fly. 


FROM   THE   LECTURE  OF    MARCH  16,   1893. 

The  day  when  the  last  lecture  was  delivered,  the  seventh 
day  of  the  disease,  the  temperature  did  not  rise  m  the  evening 
(39.2°  i^.— 102.7°^.,  as  against  39.5°  i^.  — 103.1°  I',  in  the 
morning)  ;  on  the  next,  eighth  day,  the  morning  temperature  was 
39.6°  B.  (103.2°  #.),  but  it  rapidly  fell  to  38°  R.  (100.4°  ^.)  in 
the  evening;  on  the  ninth  day  38.7°  R.  (101.6°^.)  in  the  mornmg, 
after  three  grains  of  phenacetine  38.4°  R.  (101.1°  i^.)  in  the  even- 
ing, and  on  the  tenth  day  in  the  morning,  with  the  appearance 
of  considerable  sweating,  36.2°  R.  (99.01°  _F^.),  and  since  then 
there  is  no  fever,  the  appetite  appeared  and  is  continuously 
getting  stronger.  There  was  no  further  spread  of  the  pneu- 
monic process  during  the  seventh,  eighth,  and  ninth  day  of 
the  disease ;  but  with  the  advent  of  the  crisis  the  local  phe- 
nomena underwent  a  rapid  change :  the  dullness  began  to  clear 
up,  the  bronchial  breathing  disappeared,  there  appeared  abun- 
dant rales  and  the  cough  mcreased.  Patient  took  two  bottles 
of  an  infusion  of  senega,  3j  to  fvj  a  tablespoonful  every  hour, 
and  by  the  twelfth  day  of  the  disease  —  March  10th — the 
cough  disappeared,  the  rales  vanished  and  the  percussion 
sound  at  the  region  of  the  former  pneumonia  cleared  up  en- 
tirely. To-day  the  patient,  who,  as  you  see,  is  completely 
improved,  leaves  the  clinic. 


A   FEW  NOTES   ON    OBJECTIVE   EXAM- 
INATION. 

(^From  Various  Lectures.') 


While  speaking  of  the  general  examination  of  a  patient  I 
said :  •'  By  far  not  everything  obtainable  by  examination  is 
necessary  and  important  for  medical  conclusions  ;  we  must  be 
particularly  careful  not  to  confound  diagnostic  aims  with  those 
necessary  to  semiotics,  for  not  everything  of  interest  to  the  semi- 
otician  is  necessary  to  the  diagnostician." 

As  a  matter  of  fact,  every  morbid  phenomenon  is  of  interest 
in  semiotics  as  an  independent  science,  as  a  branch  of  natural 
science,  whereas  for  diagnostic  purposes  only  that  is  of  impor- 
tance, which  forms  a  symptom,  a  sign  of  disease ;  and  the  more 
certain  the  indication  presented  by  the  morbid  phenomenon  as 
regards  the  disease,  the  more  reliable  is  this  phenomenon  as  a 
symptom,  the  more  important  does  it  become  for  diagnosis. 
Not  all  the  morbid  phenomena  possess  the  same  value  as  regards 
diagnosis  ;  on  the  contrary,  the  number  of  morbid  phenomena 
important  for  diagnostic  purposes  is  by  far  smaller  than  the 
number  of  all  the  morbid  phenomena  in  general.  If  we  were 
to  compare  the  sum  total  of  these  last,  the  knowledge  of  which 
the  student  must  acquire  during  his  study  of  semiotics,  with 
the  limited  number  of  those,  which  are  made  use  of  not  only 
by  very  experienced  and  conscientious  physicians  in  their  prac- 
tice, but  even  by  clinical  instructors,  then  we  would  find  a  great 
difference.  I  may  also  say,  that  not  only  in  private  practice, 
but  even  in  the  clinic,  are  the  methods  of  examination  less  com- 
plicated, without  losing  thereby  any  of  their  correctness,  than 
those  usually  recommended  by  text-books  and  by  the  instruc- 
tion in  semiotics. 

This  is  the  reason  why  students,  who  have  become  familiar 


—  326  — 

with  semiotics  and  who  come  to  the  clinic,  have  usually  a  gen- 
eral idea  of  the  nature  of  many  morbid  phenomena,  probably  of 
all,  but  in  the  majority  of  cases  they  are  unable  to  appreciate 
their  comparative  value  for  diagnosis,  and  cannot  separate 
the  most  important  of  these  from  the  rest ;  quite  frequently 
they  are  able  to  note  in  the  patient  some  trifling  signs,  at  the 
same  time  failing  to  perceive  valuable  symptoms. 

It  is  certainly  the  business  of  the  clinical  instructor  to  put 
prominently  before  the  mind  of  the  future  physicians  whatever 
is  most  important ;  this  is  comparativel}^  but  little,  but  they  must 
be  taught  to  firmly  possess  this  little :  it  is  however  desirable 
that  both  the  text-books  and  the  instruction  in  semiotics  have  the 
same  aim  in  view.  Some  abbreviation  of  the  course  of  instruction 
in  semiotics,  and  stricter  choice  in  the  matter  to  be  communi- 
cated to  the  students  and  in  what  is  necessary  to  be  acquired  by 
them,  would  aid  mateiially  in  reaching  such  an  aim  and  would 
be  more  than  timely  now,  when,  with  the  rapid  progress  of  the 
various  medical  sciences,  the  students  are  less  and  less  able  to 
satisfy  all  the  requirements  of  a  serious  examination. 

I  will  bring  forward  a  few  observations  which  I  usually 
make,  with  the  aim  in  view  of  pointing  out  what  is  most  impor- 
tant on  various  occasions,  in  connection  with  the  objective  ex- 
amination of  the  patient,  namely,  in  percussion,  auscultation  and 
palpation,  except  auscultation  in  diseases  of  the  heart,  on 
which  I  touched  but  slightly  in  the  preceding  lectures,  and 
which,  as  well  as  the  examination  of  this  organ,  I  expect  yet 
to  take  up  in  the  future.  To  make  the  matter  clearer  I 
shall  instance  such  a  case.  I  call  out  a  student,  and  mvite 
him  to  auscultate  the  patient  and  tell  me  what  he  hears.  In 
reply  he  says  that  he  hears  rough  breathing.  I  ask  for  the 
meaning  of  this  term,  and  what  condition  of  the  respiratory 
passages  it  indicates,  but  fail  to  obtain  a  satisfactory  answer.  I 
then  remind  the  students  and  impress  it  on  their  minds  to  al- 
ways remember  the  following  data  concerning  respiratory  mur- 
murs : 

Vesicular  respiratory  murmur  indicates,  that  the  area  over 
which  it  is  heard,  contains  normal  pulmonary  tissue,  and  con- 
sequently it  has  a  diagnostically  definite  significance.      [Each 


—  327  — 

and  every  symptom,  to  the  importance  of  which  I  call  the  at- 
tention of  the  students,  is  described  by  me,  produced,  if  pos- 
sible, by  voice  imitation,  and  is  demonstrated  on  the  patient  to 
as  great  a  number  of  students  as  practicable ;  while  the  resident 
physicians,  the  assistants  in  the  clinics,  as  well  as  the  privat- 
docenten  engaged  therein,  instruct  during  the  evening  hours 
the  students  in  the  skill  of  determining  practically  on  the 
patients  those  diagnostic  symptoms,  to  which  I  called  their 
attention.] 

Broncliial  respiratory  murmur  indicates  that  the  pulmonary 
tissue  over  which  it  is  heard  contains  no  air  (the  exception 
refers  to  the  bronchial  respiratory  murmur  transmitted  from  the 
larynx  and  trachea,  but  then  it  is  heard  usually  with  equal  dis- 
tinctness over  both  sides  of  the  chest).  Besides  the  bronchial 
and  the  vesicular  respiratory  murmurs,  which  possess  a  charac- 
teristic distinctness  in  their  acoustic  qualities  and  which  have 
a  definite  diagnostic  significance,  there  are  other  respiratory 
murmurs  which  resemble  neither  the  vesicular  nor  the  bronchial 
murmurs,  and  which  indicate  nothing  definite  (they  can  be 
found  both  in  perfectly  healthy  respiratory  passages,  as,  for  in- 
stance, in  men  when  breathing  quietly,  and  in  various  affections 
of  the  bronchi,  lungs  and  pleurae)  ;  these  therefore  possess 
no  definite  significance,  and  are  for  this  reason  called  the  indef- 
inite respiratory  murmurs.  To  this  class  must  be  referred  the 
so-called  rough  breathing  ;  and  to  distinguish  this  is  for  the  diag- 
nostician but  an  unnecessary  burdening  of  the  memory  by  a 
rhetorical,  but  not  a  diagnostic  term.  Once  the  respiratory 
murmur  is  neither  vesicular  nor  bronchial,  it  has  no  diagnostic 
significance,  and  is  therefore  of  an  indefinite  quality  ;  whether 
it  be  rough  or  otherwise  is  of  no  importance.  Under  certain 
conditions,  but  not  independently  by  itself,  the  indefinite  res- 
piratory murmur  (i.  e.  the  one  resembling  neither  the  bronchial 
nor  the  vesicular,  and  whether  it  be  rough  or  otherwise  is 
not  important)  may  possess  a  diagnostic  importance ;  thus,  for 
example,  if  under  one  clavicle  we  hear  a  vesicular  respiratory 
murmur,  and  under  the  other  constantly  an  indefinite  one,  for 
instance,  the  so-called  prolonged  expiration,  one  of  the  varieties 
of  the  indefinite  respiratory  murmur,  especially  in  a  patient, 


—  328  — 

who  excites  a  suspicion  of  tuberculosis,  tlien  we  have  a  founda- 
■  tion  to  conclude,  even  before  the  appearance  of  the  more  positive 
symptoms,  such  as  rales  and  alterations  in  the  percussion  sound, 
that  that  pulmonary  apex  is  affected,  over  which  we  hear  the 
indefinite  respiratory  murmur. 

In  connection  with  the  same  we  must  also  make  the  follow- 
ing observations : 

About  rales.  —  We  must  distinguish  dry  rales  (usually 
whistling  ones)  and  moist  rales ;  of  the  latter,  the  very  fine 
ones,  crepitant,  as  typically  represented  in  the  beginning  of  a 
pneumonia,  then  somewhat  more  prominent,  subcrepitant,  as 
typically  represented  at  the  stage  of  resolution  of  a  pneumonic 
process  and  at  the  beginnmg  of  an  oedema  of  the  lungs, 
and  finally  the  medium  and  the  coarse  rales,  as  typically 
represented  by  a  pulmonary  cedema  which  spread  upward, 
and  by  a  bronchial  catarrh  with  abundant  expectoration. 

Then  I  advise  to  memorize  well  the  nature  of  the  rales  which 
characterize  the  most  frequent  affections  of  the  respiratory  organs. 

1.  Abundant  moist  rales,  at  the  beginning  subcrepitant,  later 
more  coarse,  which  appear  simultaneously  on  both  sides  of  the 
chest,  at  first  under  the  scapulae  and  later  spreading  further  and 
further  upward  (and  parallel  with  this  the  dyspnoea  becomes 
aggravated),  pomt  with  certainty  to  pulmonary  oedema,  which 
increases  rapidly  and  requires  immediate  treatment.  2.  Less 
abundant  moist  rales  on  both  sides  under  the  scapulae,  which 
remain  constantly  subcrepitant  and  do  not  spread  upward,  and 
which  are  usually  heard  on  deep  inspiration,  ordinarily  in  per- 
sons with  a  distended  abdomen  and  a  highly  elevated  diaphragm, 
—  which  condition  prevents  a  full  expansion  of  the  lower 
pulmonary  parts,  —  point  partly  to  a  condition  of  atalectasis, 
partly  to  a  slight  stationary  oedema  of  these  parts.  3. 
Rales  which  are  heard  on  either  side  only  over  the  middle 
portions  of  the  lungs,  and  which  are  not  perceived  in  the  apices 
and  the  lowest  portions,  now  more  diy,  now  more  moist,  medium 
and  large  bubbling  ones,  point  to  a  bronchial  catarrh,  either 
dry  or  moist.  As  a  very  rare  exception  I  have  seen  an  un- 
complicated bronchial  catarrh  (without  any  affection  of  the 
pulmonary  tissue)  on  one  side,  which  lingered  from   the   very 


—  329  — 

childhood  of  the  patient,  at  times  quieting  down,  at  others,  dur- 
ing the  cold  season,  taking  on  an  acute  form,  the  predisposition 
to  which  catarrhal  condition  was  evidently  determined  by  an  in- 
sufficient expansion  of  the  affected  half  of  the  chest  during  the 
early  part  of  life  (semiatalectasis  of  the  lung  ?).  On  the  other 
hand  the  above-mentioned  rales,  if  considerably  spread  over  both 
halves  of  the  chest,  may  be  heard  in  bronchopneumonia  — 
most  frequently  of  tubercular  origin  —  which  attacked  both 
lungs  (the  differential  diagnosis  between  bronchial  catarrh  and 
tubercular  bronchopneumonia  was  spoken  of  in  connection  with 
the  twenty-first  case).  4.  Moist  rales,  observed  over  a  limited 
area,  in  one  focus  or  in  several,  point  to  an  affection  of  the 
lung  tissue,  —  croupous  pneumonia,  pneumonia  complicating 
grippe,  pertussis,  etc. ;  such  a  focus  exhibiting  moist  rales  in  the 
apex  of  one  or  the  other  lung  or  of  both  forms  one  of  the  most 
certain  symptoms  of  tuberculous  affection  of  the  lungs. 

In  some  cases  —  as  in  pneumothorax  and  in  cavernse  —  the 
respiratory  murmurs  and  rales  may  possess  a  particular  quality 
of  resonance  (simple  and  metallic),  at  times  of  such  a  pro- 
nounced and  characteristic  nature,  as  to  plainly  point  to  the 
above-named  morbid  conditions. 

The  percussion  sound.  —  The  principal  quality  of  this,  which 
must  chiefly  be  taken  into  account,  is  its  force  :  a  clear,  a  dull 
or  a  flat  sound.  In  rare  cases  the  percussion  sound  over  the 
chest,  ordinarily  not  resonant,  may  possess  a  similar  pronounced 
resonant  quality  as  the  phenomena  observed  in  auscultation;  it 
then  has  a  similar  diagnostic  significance. 

Determination  of  the  dimensions  of  the  heart.,  liver  and  spleen.  — 
The  dimensions  of  the  heart  are  firstly  determined  by  palpating 
the  region  of  the  heart-impulse  at  the  apex  (I  recommend  most 
earnestly  exercise  in  such  examination,  as  it  gives  most  im- 
portant data),  and  secondly  by  percussion  over  the  sternum :  in 
the  normal  condition  the  lower  half  of  the  sternum  gives  almost 
as  clear  a  percussion  sound,  as  the  upper  one  ;  while  in  case  of 
an  enlarged  heart,  and  especially  of  its  right  half,  the  per- 
cussion sound  over  the  lower  half  of  the  sternum  and  to  its 
right  is  duller  than  over  the  neighboring  parts  —  upward  and 
to   the   right — of  the   chest   wall  and  the  upper  half  of  the 


—  330  — 

sternum.  The  area  of  the  apex  beat  of  the  heart  and  the  right 
border  of  the  dull  sound  at  the  cardiac  region,  present  entirely 
sufficient  data  by  which  we  can  judge  of  the  dimensions  of 
this  organ. 

The  lower  border  of  the  liver  and  of  the  spleen  is  determined 
by  palpation,  and  the  upper  border  hy  percussion.  While  per- 
forming the  last  it  is  hardly  worth  while  to  search  for  the  rib 
to  which  it  extends.  The  statement  of  the  text-books  "  from 
this  rib  to  that "  are  but  average  deductions  from  many  ob- 
servations. Every  individual  case  will  present  departures 
from  these  mean  dimensions.  Consequently,  if  such  depar- 
tures be  small,  then  we  cannot  deduct  therefrom  any  conclu- 
sion as  regards  the  alteration  in  the  size  of  the  organ;  but  if 
they  be  considerable,  then  there  is  no  necessity  to  occupy  one- 
self with  recounting  the  ribs :  for  it  is  plainly  apparent,  that 
the  area  between  the  superior  and  the  inferior  borders  is 
markedly  greater,  or  pronouncedly  less  extensive,  than  is 
peculiar  to  the  organ  in  its  normal  condition.  It  also  suffices 
an  experienced  look  to  judge  by  this  area  as  to  whether  the 
organ  is  replaced  or  not.  This  is  the  reason  why  I  insist,  for 
the  sake  of  acquiring  such  experience,  on  exercising  as  much  as 
possible  in  defining  the  borders  of  the  hver  and  of  the  spleen, 
and  thus  acquire  a  strong  mental  hold  on  the  dimensions  as 
well  as  the  localization  of  the  area  contained  within  the  above- 
named  borders  in  the  normal  condition  of  these  organs,  as 
well  as  when  they  are  enlarged,  diminished  and  replaced. 

The  importance  of  feeling  the  pulse,  at  one  time  somewhat 
forgotten,  thanks  to  the  enthusiasm  generated  by  the  method 
of  percussion  and  auscultation  and  also  to  sphygmography, 
but  at  the  present  time  appreciated  rightly,  requires  certainly 
no  necessity  for  discussion.  Of  the  many  peculiarities  of  the 
pulse  we  must  at  all  times  define  its  three  principal  qualities  : 
its  frequency,  rhythm  and,  most  important  of  all,  its  strength. 
The  strength  of  the  pulse  depends  on  the  quantity  of  blood,  on 
the  force  of  the  cardiac  contractions  and  on  the  elasticity  of  the 
arteries.  Feeling  the  pulse  enables  one  to  judge  certainly  only 
of  the  results  of  interaction  of  these  factors.  To  determine  the 
condition  of  these   last   we  must  consider  the  other  data,  the 


—  331  — 

condition  of  nutrition  and  hsematopoiesis,  and  the  results  of  the 
examination  of  the  heart  and  of  the  arterial  system.  Sphygmo- 
graph}^  and  sphygmomanometry,  not  to  speak  of  the  great 
inconvenience  their  use  occasions  in  private  practice,  cannot 
replace  the  determmation  of  the  qualities,  prmcipally  of  the 
strength,  of  the  pulse,  nor  of  the  condition  of  the  arteries  as 
obtained  by  touch.  We  shall  yet  have  occasion  to  speak  of  the 
pulse,  as  well  as  of  auscultation  of  the  heart,  when  analyzing 
clinically  the  diseases  of  this  organ. 


ELEMENTS  OF  BALNEOTHERAPY 

FOR  THE  PRACTICAL  PHYSICIAN. 


LECTURES   OF  APRIL  20  AND  21,  1893. 

While  giving  clinical,  that  is,  practical  instruction  in  pathol- 
ogy and  therapeutics,  the  clinician  embraces  the  opportunity, 
in  prescribing  the  treatment,  to  touch  on  all  the  means  pos- 
sessed, by  this  last,  and  in  doing  this  he  is  enabled  to  classify 
these  means  from  his  own  special  clinical,  principally  individ- 
ualizing point  of  view.  I  therefore  since  long,  almost  from  the 
very  beginning  of  my  clinical  activity,  always  touched  upon  the 
subject  of  balneotherapy.  In  former  times  this  was  the  more 
necessary,  as  the  student  at  the  clinic  had  almost  no  idea  about 
this  subject,  because  it  formed  no  part  of  the  curriculum  of 
university  instruction.  During  recent  years  among  the  various 
courses  of  our  medical  schools  there  were  also  established  courses 
in  balneotherapy,  but  I  still  keep  to  my  custom  of  discussing 
the  subject  in  my  lectures ;  in  doing  this  I  am  also  urged  on  by 
my  former  students,  who  attest  to  the  value  of  these  lectures 
by  their  own  experience.  As  far  as  the  internal  employment 
of  mineral  waters  is  concerned,  I  spoke  of  the  necessity  of  its 
clinical  characteristic  ;  but  there  is  another  reason  for  the  utility 
of  such  a  characteristic  of  balneotherapy,  which  is  common  to 
both  the  external  and  the  internal  employment  of  mineral 
waters. 

The  reason  for  this  lies  in  the  practice,  common  to  all  hand- 
books, text-books  and  courses  of  balneotherapy,  of  expounding 
together  the  employment  of  mineral  waters  both  for  external 
and  internal  uses,  while  discussing  the  subject  in  general,  as 
well  as  in  the  description  of  special  kinds  of  mineral  waters. 
The  subject  of  balneotherapy  in  general,  that  is,  the  science 
of  the  application  of  mineral  waters  for  external  and  internal 
332 


—  333  — 

use,  is  very  extensive,  extremely  complicated  and  varied ;  there 
is  hardly  a  department  of  special  pathology  on  which  it  does  not 
touch.  By  the  internal  use  of  the  mineral  waters  we  aim  principal- 
ly to  influence  the  mucous  membranes,  the  blood,  the  nutrition  and 
the  various  secretions,  and  through  all  these,  the  nervous  system ; 
while  by  their  external  use  we  act  through  the  skin  on  the 
nervous  system,  and  then  through  this  last  on  the  other  parts 
of  the  organism.  It  is  thus  apparent,  that  the  numerous  and 
various  diseases,  for  which  the  mineral  waters  are  administered 
internally,  differ  from  the  great  number  and  variety  of  diseases, 
in  which  they  are  applied  externally ;  it  is  consequently  but 
too  evident  how  different  may  be  the  indications  for  the  in- 
ternal use  of  mineral  waters  from  those  for  the  external  use  of 
the  same.  To  this  we  must  subjoin  the  following  :  that  the 
experience  proving  the  effectiveness  of  the  mineral  waters  was 
obtained  at  the  places  where  these  are  located,  and  consequent- 
ly their  curative  efficacy,  as  shown  in  certain  diseases,  was  due 
not  only  to  their  employment,  but  also  to  the  peculiar  charac- 
teristics of  these  localities,  to  the  climatic,  dietetic  and  general 
conditions,  as  well  as  to  the  change  in  the  mode  of  living  of  the 
patients  who  took  up  their  residence  there.  To  correctly  ap- 
preciate the  proper  action  of  the  mineral  waters,  balneotherapy 
must  take  into  consideration  also  these  last  influences,  climatic 
and  otherwise,  generally  hygienic.  All  these  balneotherapy  must 
consequently  touch  upon.  This  many-sidedness  of  the  subject, 
which  is  determined  by  the  great  variety  of  its  contents,  consti- 
tutes a  great  obstacle  in  penetrating  into  the  true  nature  of 
balneotherapy,  especially  so  for  the  beginner,  who  in  a  general 
way  finds  it  difficult  to  differentiate  the  enormous  mass  of  ma- 
terial T)ffered  to  him  for  acquisition  during  the  few  years  of  his 
university  (medical")  course. 

Therefore  to  better  define  the  so  important  therapeutic  value 
of  the  mineral  waters  proper,  I  continue  to  discuss  this  sub- 
ject also  at  the  present  time  during  my  clinical  instruction ;  and 
for  the  sake  of  still  greater  clearness  I  discuss  the  internal  use 
of  the  mineral  waters  separately,  and  the  external  use,  or  halneo- 
therapi/  in  the  narroiv  acceptation  of  the  term,  also  separately,  after 
you  had  been  shown  during  the  course  of  the  year  the  applica- 


—   334  — 

tion  of  various  balneotherapeutic  agencies,  —  as  the  warm  baths, 
hot  air-baths,  douches,  cold  and  warm  compresses,  etc.  ;  all  these 
were  demonstrated  and  explained  to  you,  as  well  as  the  indications 
for  the  use  of  other  similar  agencies,  as,  for  instance,  alkaline 
baths  in  the  cases  we  came  across  (thus  in  the  thirteenth  case). 

In  speaking  of  balneotherapy  in  the  narrow  sense  of  the  word 
(the  external  use  of  waters)  I  only  aim  to  give  its  fundamental 
principles,  the  most  important  which  should  always  be  fresh  in  the 
memory  and  clear  to  the  understanding  of  the  practical  physi- 
cian, and  which  are  not  always  clearly  defined,  but  rather  made 
vague  in-  the  above-mentioned  complicated  and  diversfied  treat- 
ment of  the  subject  by  handbooks,  text-books  and  various 
courses.  The  exposition  of  this  most  important  matter  is  sub- 
divided into  three  parts :  the  action  of  the  waters,  the  varieties 
of  the  same,  and  a  short  sketch  of  diseases  in  which  the  waters 
are  applied  externally. 

The  action  of  waters  in  their  external  application  is  principally 
determined  by  their  temperature,  and  to  a  lesser  extent  by  their 
composition  and  mechanical  effect. 

I.  The  Effect  of  the  Temperature  of  the  Waters. 

1.  O71  the  nervoiis  system.  —  Waters,  the  temperature  of  which 
approaches  that  of  the  surface  of  the  body — 27°  R.  (92.8°  F.^ 
to  28°  R.  (95°  F.^  —  are  known  as  thermically  indifferent ;  with 
a  higher  temperature  —  29°  R.  (97.2°  i^.)  and  more —  as  warm 
or  hot;  with  a  lower  temperature  —  26°  R.  (90.6°  i^.),  and  less 
—  as  cool  or  cold. 

The  thermically  indifferent  waters  exert  by  themselves  no 
effect  on  the  nervous  system ;  but  by  keeping  the  body  in  an 
equable  temperature,  they  protect  it  from  the  irritation  pro- 
duced by  the  constantly  changing  external  temperature,  and 
thus  induce  a  quieting  effect.  Cold  baths  exert  a  stimulating 
effect  on  the  central  nervous  system,  calling  forth  a  spirited 
mental  state  and  a  desire  for  mental  and  physical  activity,  and 
remove  contrary  conditions.  Warm  baths  act  on  the  nervous 
system  in  a  weakening  manner,  causing  fatigue,  unwillingness 
to  work  and  inclination  to  sleep ;  they  quiet  the  condition  of 
excitement.     Such  an  effect  of  the  cold  and  of  the  warm  baths 


—  335  — 

is  observed  in  the  majority  of  cases,  but  there  occur  also  nu- 
merous exceptions  ;  in  describing'  the  external  use  of  waters  in 
diseases  of  the  nervous  system  I  shall  speak  of  this  more. 

The  effect  of  baths  on  the  central  nervous  system  may  take 
place  through  various  ways  :  directly  in  a  centripetal  way 
through  the  sensory  nerves  of  the  skin,  through  reflex  action  on 
the  vasomotors  of  the  cerebral  and  the  cerebro-spinal  vessels, 
and  consequently  through  alterations  in  the  cerebral  and  cere- 
bro-spinal distribution  and  circulation  of  blood,  through  the  va- 
cillations produced  in  this  last  by  changes  which  are  caused  by 
the  baths  in  the  general  circulation  (as,  for  instance,  by  the  in- 
flux of  blood  to  the  external  parts  after  warm  baths),  later  on 
through  alterations  produced  by  baths  in  the  general  nutrition. 
By  influencing  the  nervous  centres  through  the  skin,  the  baths 
may  exert  an  effect  through  these  last  on  all  the  nervous  func- 
tions —  sensation  and  motion,  nutrition  and  secretion.  The 
mechanism  of  this  action  is  not  known  with  certaint}^,  but  the 
fact  of  its  existence  is  beyond  any  doubt ;  thus :  warm  baths 
quiet  pains  and  convulsions,  cold  baths  may  call  out  muscu- 
lar contractions,  as  evidenced  in  the  treatment  of  constipation 
by  cold  douches  on  the  abdomen  or  into  the  rectum ;  later  on 
we  shall  discuss  the  important  changes  which  may  be  produced 
by  baths  of  various  temperatures  on  the  temperature  of  the  body, 
on  the  body  metabolism,  on  the  secretions,  on  the  calibre  of  the 
vessels,  distribution  and  movement  of  the  blood  and  lymph,  and 
the  activity  of  the  heart  and  the  respiration ;  all  these  changes, 
as  I  said  before,  are  reflected  in  their  turn  in  the  condition  of 
the  nervous  system. 

2.  On  the  temperature  of  the  body.  —  The  thermically  indifferent 
baths,  produce  no  marked  effect  on  the  loss  and  production  of 
heat  by  the  body.  In  cool  and  cold  baths,  up  to  a  certain  de- 
gree of  cold  and  within  a  certain  limit  of  time,  the  body  is  at 
first  chilled,  but  later  on  it  becomes  rapidly  warm  and  the  in- 
ternal bodily  temperature  is  not  lowered,  but  remains  normal, 
or  is  even  raised.  Similar  to  the  action  of  cold  baths  is  that  of 
other  cooling  hydrotherapeutic  procedures,  as  douches,  semi- 
baths,  sponging  with  a  wet  towel.  The  constancy  of  the  inter- 
nal bodily  temperature  in  the  presence  of  a  considerable  loss  of 


—  336  — 

heat  in  a  cold  bath  is  determined  by  the  diminution  of  this  loss 
as  caused  by  the  contraction  of  the  peripheral  vessels  and  by 
the  increased  production  of  heat  in  the  body.  But  if  the  degree 
of  cold  and  the  time  during  which  the  bath  is  being  taken  ex- 
ceed certain  limits  —  which  are,  of  course,  variable  in  different 
cases  —  then  the  body,  having  become  warmed  after  the  first 
chill,  is  chilled  anew,  does  not  any  more  become  warmed  either 
in  the  bath  or  out  of  it,  and  is  subjected  to  an  abnormal  state, 
which  is  made  apparent  by  a  condition  of  general  weakness,  in- 
stead of  stimulation,  by  loss  of  appetite,  and  by  a  red  saturated 
urine  containing  a  great  amount  of  urea  and  uric  acid.  If  the 
use  of  such  baths  or  of  similar  hydrotherapeutic  procedures  be 
resorted  to  repeatedly  during  a  careless  and  negligent  treatment, 
then  there  is  established  a  genuine  febrile  condition,  accompa- 
nied by  emaciation  of  the  body,  which  may  lead  eventually  to  a 
serious  disturbance  of  health ;  any  curative  effect  of  such  a 
treatment  is  certainly  out  of  the  question. 

Warm  and  hot  baths  prevent  the  loss  of  heat  by  the  body 
and  even  bring  warmth  to  the  body,  and  therefore  the  internal 
bodily  temperature  is  raised  while  in  them  ;  thus  Mosler  observed 
that  in  baths  of  40°  G.  (104°  ^.)  to  44°  C.  (111.2°  1^.)  the 
temperature  in  the  cavity  of  the  mouth  was  raised  to  38.6°  H. 
(118.8°  -F.),  and  Bartels  noted  that  after  a  ten  minutes'  stay  in 
the  steam  bath  at  the  temperature  of  53°  G.  (about  127°  i^.) 
the  temperature  in  the  rectum  was  raised  from  38°  Ft.  to  40.4°  R. 
(about  122.5°  F.y 

3.  On  the  tissue  metabolism  and  on  the  secretions.  —  The  ther- 
mically  indifferent  baths,  not  influencing  the  loss  and  produc- 
tion of  heat  by  the  body,  exert  no  marked  effect  on  the  tissue 
metabolism  and  on  the  secretions. 

Cold  baths,  and  generally  the  loss  of  heat,  increase  the 
excretion  and  consequently  the  production  of  carbonic  acid,  i.  e. 
the  combustion  of  fats,  in  proportion  to  the  degree  of  this  loss, 
and  consequently  to  the  increased  production  of  heat ;  the  body 
becomes  lean.  If  the  degree  of  cold  and  the  duration  of  the 
bath  are  kept  within  the  above-mentioned  limits,  so  that  the 
body,  after  becoming  warm  after  the  first  chill,  is  not  chilled 
later  on,  then  the  excretion  of  urea,  representing  the  disinte- 


-  337  — 

gration  of  the  albumens,  is  not  altered  by  such  baths ;  but  if 
these  limits  are  exceeded,  that  is,  if  the  body,  having  become 
warm  after  the  first  chill,  is  later  on  chilled  again  and  does  not 
become  warmed  any  more,  then  there  develops  a  morbid  condi- 
tion which  passes  into  fever,  and  with  this  the  excretion  of 
urea  and  of  uric  acid,  representing  the  disintegration  of  the 
albumens,  becomes  increased. 

Hot  baths,  by  raising  the  temperature  of  the  body,  increase 
both  the  excretion  of  urea,  which  means  the  disintegration  of  the 
albumens,  and  the  excretion  of  carbonic  acid,  i.  e.  the  combus- 
tion of  fats.  After  warm,  and  particularly  after  hot  baths,  the 
body  perspires  (consequently  it  loses  heat),  while  the  amount 
of  urine  is  diminished  and  its  concentration  is  increased. 

4.  On  the  circulation  and  respiration.  —  The  thermically  in- 
different baths  exert  no  marked  effect  on  the  calibre  of  the 
vessels,  and  consequently  also  on  the  distribution  of  blood 
throughout  the  body,  on  the  frequency  and  force  of  the  cardiac 
contraction  (the  pulse),  nor  on  the  frequency  and  depth  of  the 
respiratory  movements. 

The  body  becomes  first  pale  in  a  cold  bath,  as  its  vessels  are 
constricted,  then  the  color  changes  to  red,  the  vessels  dilating 
and  the  circulation  growing  quicker,  these  phenomena  remain- 
ing after  the  bath;  in  the  unnecessarily  cold  and  prolonged 
baths,  the  skin  takes  on  a  blue  tinge,  which  is  a  sign  of  venous 
hypersemia  and  of  slackened  circulation. 

In  a  hot  bath  the  skin  grows  red,  on  account  of  a  dilatation  of 
the  vessels,  which  effect  lasts  for  some  time  also  after  the  bath. 
Very  hot  water,  the  application  of  which  is,  of  course,  possible 
only  in  a  local  way,  determines  a  contraction  of  the  vessels  ; 
this  is  the  basis  for  certain  therapeutic  measures  in  gynsecology, 
as  the  use  of  hot  vaginal  douches  for  metrorrhagise  and  to  assist 
in  the  absorption  of  exudations  formed  as  a  result  of  a  parame- 
tritis. 

In  a  cold  bath  the  contractions  of  the  heart,  the  pulse,  be- 
come stronger  and  are  at  first  more  frequent  (because  the  simul- 
taneous contraction  at  the  beginning  of  the  peripheral  vessels 
increases  the  blood-pressure  and  thus  excites  the  activity  of  the 
left  ventricle),  but  grow  less  frequent  later  on. 


■   —  338  — 

In  a  hot  bath  the  contractions  of  the  heart,  the  pulse,  become 
more  frequent  and  weak  in  proportion  to  the  rise  of  the  internal 
bodily  temperature. 

In  a  cold  bath  the  respiratory  movements  become  deeper  and 
more  frequent  in  proportion  to  the  excretion  of  carbonic  acid. 
In  a  hot  bath  the  respiratory  movements  become  more  frequent 
in  proportion  to  the  increase  of  the  internal  bodily  temperature 
and  to  the  increased  excretion  of  carbonic  acid. 

II.  The  Effects  of  the  Component  Parts  of  the  Waters. 

The  most  important  component  parts  of  the  waters  used 
externally  are  common  salt,  carbonic  acid  and  sodium  carbon- 
ate. 

Experiments  have  shown,  that  a  salt  bath,  containing  three 
per  cent  of  common  salt,  increases  (as  compared  with  a  bath  of 
water  not  containing  any  salt,  at  the  same  temperature  and  of 
the  same  duration)  the  consumption  of  oxygen  and  the 
excretion  of  carbonic  acid ;  this  effect  does  not  take  place,  if 
the  nerve-endings  be  paralyzed  by  curare.  From  this  it  be- 
comes apparent,  that  the  sodium  chloride  in  the  above-named 
concentrated  solution  irritates  the  nerve  endings  of  the  skin 
and  in  this  way  exerts  a  strong  influence  on  the  metabolism  and 
on  the  secretions.  Medical  observations  concerning  the  effec- 
tiveness of  salt  baths,  as  in  scrofulosis,  rickets,  unabsorbed 
exudations,  etc.,  have  long  ago  proved  the  fact  of  such  an 
influence.  Salt  baths  of  the  above-named  concentrated  solu- 
tion cause  the  superficial  vessels  first  to  contract  (the  skin 
becomes  pale),  and  later  on  to  strongly  and  continuously  dilate 
(the  skin  grows  red  and  remains  so  for  quite  a  considerable 
time  after  the  bath)  ;  thus  the  salt  baths,  besides  mfluencing 
the  circulation,  and  consequently  the  nutrition  of  the  general 
integuments,  may  also  exert  an  influence  on  the  distribution  of 
the  blood  throughout  the  body,  and  through  this  means  as  well  as 
by  the  above-mentioned  irritation  of  nerves  of  the  skia,  also  on 
the  nervous  sj^stem. 

The  carbonic  acid,  when  present  in  the  bath  in  a  sufficient 
quantity,  irritates  the  peripheral  endings  of  the  nerves  and  in 
this  way  acts  as  a  stimulant  to  the  nervous  system. 


—  339  — 

The  sodium  carbonate,  in  the  quantity  found  in  the  alkaline 
waters  employed  for  bathing  purposes,  causes  but  a  slight  irri- 
tation of  the  peripheral  endings  of  the  nerves,  rather  contrari- 
wise, quieting  them,  improving  the  condition  of  the  skin  by  the 
fact  that  it  assists  in  the  removal  of  the  fats  (by  saponifying 
them)  as  they  accumulate  in  the  mouths  of  the  glands  of  the 
skin,  and  also  in  the  removal  of  the  epidermis. 

Sulphur  seems  to  exert  some  effect  on  the  skin,  because  sul- 
phur baths  proved  to  be  beneficial  in  certain  cutaneous  affec- 
tions ;  any  further  effect  than  that  the  sulphur  baths  do  not 
apparently  exert,  and  they  are  also  considered  as  chemically 
indifferent  waters. 

Other  bodies  found  in  mineral  waters  employed  for  baths, 
do  not  cause  any  marked  effects. 

The  substances  found  in  the  mineral  muds,  as  the  organic 
acids,  sodium  chloride,  iron  sulphate  and  other  salts,  exert  an 
irritating  effect  on  the  peripheral  nerve  endmgs,  as  may  be 
inferred  from  the  curative  effect  of  the  muds,  but  we  possess 
ng  positive  knowledge  concerning  this  subject. 

Even  if  absorption,  in  the  bath,  of  certain  substances  by  the 
body  does  take  place,  it  is  of  such  trifling  extent,  that  it  pos- 
sesses no  practical  significance. 

III.  The  Effect  of  Mechanical  Influences  during  the  External 
Use  of  Waters. 

The  mfluences  of  such  a  nature,  as  in  out-door  bathing  the 
current  in  the  river  and  the  waves  in  the  sea,  the  concussions  of 
the  skin  in  the  fan-like  douches  under  a  high  pressure,  the 
friction  in  the  half-baths  and  m  the  wet  spongings,  and  various 
other  massage-like  procedures,  act  as  irritants  on  the  skin,  i.  e. 
in  the  same  sense  as  the  thermic  and  the  chemical  agencies,  and 
consequently  they  enhance  the  effect  of  these  last.  The 
movements  made  by  the  patient,  as  in  swimming  and  other 
movements  in  sea-bathing,  friction  of  one's  own  body  in  the 
front  in  half-baths  and  wet  spongings,  exert  an  influence  on  the 
metabolism  and  on  the  secretions,  on  the  circulation  and 
respiration  in  the  same  way  as  the  above-mentioned  agencies. 


—  340 


THE  VAEIOUS  CLASSES  OF  WATERS. 

1.  The  chemically  indifferent  tvaters,  usually  warm  (acrato- 
thermse),  contain  but  one  or  less  to  a  thousand  of  component 
parts  —  usually  of  alkaline  carbonates,  chlorates  or  sulphates  — 
namely,  not  more  than  any  river  water,  and  therefore  they  act 
only  by  their  temperature.  They  are  used  either  as  ihermically 
indifferent  waters,  which  protect  the  body  from  irritation  by  the 
continuously  changing  external  temperature,  which  means  that 
they  quiet  the  nervous  system  in  various  nervous  disorders, 
especially  in  those  in  which  the  symptoms  of  hypersesthesia  pre- 
vail, principally  in  neurasthenia  and  in  hysteria  ;  or  they  are  em- 
ployed in  the  form  of  warm  and  hot  baths,  deriving  the  blood 
towards  the  periphery  in  hypersemia  of  the  internal  organs, 
and  exert  a  pronounced  effect  on  metabolism  and  absorption  in 
the_  several  varieties  of  chronic  polyarthritis,  gout,  syphilis,  and 
metallic  poisonings.  Of  the  well  known  waters  of  this  class  I 
shall  name  as  examples,  Schlangenbad,*  Ragatz,f  Gastein,| 
Teplitz,§  Leuk,||  Plombieres,^  Abas-Touman.**     To  this  class 

*  In  the  province  of  Hesse-Nassau,  Prussia,  six  miles  west  of  Wiesba- 
den. 

t  In  the  canton  of  St.  Gall,  Switzerland,  situated  on  the  Tamina  in  lat. 
47°  N.,  long.  9°  30'  E.  It  is  noted  for  its  hot  springs,  and  has  about  fifty 
thousand  visitors  annually. 

I  A  valley  in  the  crown  land  of  Salzburg,  Austria-Hungary,  south  of 
Salzburg.  It  is  famous  for  its  picturesque  scenery.  At  Wilbad-Gastein 
there  are  hot  springs. 

§  A  town  and  watering  place  in  Northern  Bohemia,  situated  in  the  val- 
ley of  the  Biela,  near  the  mountains,  forty-six  miles  northwest  of  Prague. 
It  is  one  of  the  most  frequented  places  in  Europe,  and  has  been  the  scene 
of  several  conferences  of  princes.     Population  in  1890  (commune),  17,526. 

II  Leuk  (loik),  P.  Loueche  (lo-esh),  a  village  in  the  canton  of  Valais, 
Switzerland,  situated  on  the  Rhone,  fourteen  miles  northeast  of  Sion. 

1  In  the  department  of  Vosges,  France,  situated  on  the  Augrogne, 
fifteen  miles  south  of  Epinal.  It  has  the  most  important  mineral  springs 
in  the  Vosges,  with  thermo-mineral,  iron  and  alkaline  baths.  It  was 
known  to  the  Romans  and  was  greatly  developed  by  Napoleon  III. 

**  A  watering  place  on  the  Caucasus. 


—  341  — 

also    belong    the    sulphur    waters,    as,    for   instance,    those  of 
Aachen  *  and  of  Pyatigorsk.f 

I  must  now  make  some  general  remarks  concerning  not 
only  the  enumerated  watering  places,  but  any  others  as  well. 
It  were  a  great,  unpardonable  error,  in  view  of  the  fact  that  the 
above-named  (and  any  other)  watering  places  are  classified  in 
one  category,  to  consider  them  as  identical  and  to  send  patients 
there  indiscriminately,  as,  for  instance,  to  send  a  nervous,  ema- 
ciated female  patient,  for  whom  the  thermically  indifferent  baths 
are  suitable,  to  Teplitz  or  Pyatigorsk,  where  the  warm  and  hot 
springs  are  situated,  and  to  send  a  gouty  patient,  with  a  multiple 
arthritis,  who  would  be  benefited  hj  warm  or  even  hot  baths,  to 
Schlangenbad  with  its  thermically  indifferent  baths.  This  would 
be  as  great  an  error  as  if  we  were  to  prescribe  for  a  patient  Ems 
while  he  needs  Marienbad,  or  on  the  contrary.  Every  watering 
place  possesses  certain  peculiarities  which  must  be  taken  into 
consideration.  These  peculiarities  depend  on  numerous  con- 
ditions. The  difference  in  the  temperature  of  the  baths  was 
spoken  of  before.  The  method  of  employing  them  is  also  of 
importance.  Let  us  take,  for  the  sake  of  comparison,  Franzens- 
bad  and  Saki  (in  Crimea,  near  Eupatoria).  In  both  places 
mkieral  moor  is  employed,  but  in  Franzensbad  it  is  added  to  a 
water  bath  of  a  mostly  thermically  indifferent  temperature,  and 
the  bath  is  taken  within  a  closed  space,  while  in  Saki  the  pa- 
tient is  put  directly  into  a  mass  of  mud  which  has  been  pre- 
pared since  morning  in  the  open  air  and  which  was  strongly 
heated  by  the  rays  of  the  sun,  and  he  is  covered  up  with  a  simi- 
lar mass  of  mud,  so  that  the  temperature  of  such  a  bath  is  raised 
high,  and  the  bath  is  a  hot  one.  It  is  self-understood  that  Fran- 
zensbad benefits  a  different  class  of  patients,  than  are  benefited 
by  Saki.     To  Franzensbad  flock  nervous,  emaciated  men  and 

*  Aaclien  is  the  German  name  for  Aix-la-Chapelle,  in  the  Rhine  prov- 
ince, Prussia,  about  lat.  50°  46'  X.,  long.  6°  5'  E.,  an  imjHjrtant  commer- 
cial and  railway  centre.  It  was  founded  by  the  Romans  as  a  watering- 
place. 

t  A  town  in  the  Terek  Territory,  Ciscaucasia,  Russia,  situated  on  an 
affluent  of  the  Kuma  in  lat.  44°  4'  N.,  long.  42°  8'  E.  It  is  noted  as  a 
watering  place  on  account  of  its  sulphur  springs.  Pojiulation  in  1889, 
13,114. 


—  342  — 

women  (we  shall  have  occasion  later  to  speak  of  the  use  of 
moor-baths  hi  Franzensbad  for  diseases  of  women),  because 
many  observers  have  proved  that  the  thermicallj  indifferent 
moor-baths  exert  frequently  even  a  greater  quieting  effect  on 
the  nervous  system,  than  the  thermically  indifferent  baths  of  the 
chemically  indifferent  springs  (acrato thermae).  In  Saki  you 
will  see  gouty  and  syphilitic  patients  with  inveterate  affections 
of  many  joints,  and  others  in  whom  it  is  expected  the  hot 
baths  will  exert  a  strong  influence  on  the  metabolism  and 
absorption. 

A  particularly  important  part  m  determining  the  special 
peculiarities  of  the  various  watering  places  is  to  be  attributed 
to  their  climate.  To  better  explain  its  influence,  let  us  continue 
the  former  comparison  between  Franzensbad  and  Saki.  Pa- 
tients with  weak  nerves,  who  usually  bear  heat  badly,  would 
be  harmed  by  a  sojoui'n  during  the  extremely  hot  summer  at 
Saki,  but  on  the  contrary  they  would  profit  by  the  cool  summer 
of  the  Franzensbad  valley ;  whereas  for  patients,  who  are  bene- 
fited by  the  hot  mud-baths  (and  these  in  the  open  air),  the  hot 
summer  in  Saki  would  be  very  suitable,  but  not  the  cool  sum- 
mer at  Franzensbad,  that  may  bring  on  a  cold  in  a  locality 
much  visited  and  exposed  to  every  wind. 

Another  example :  both  Gastein  and  Pyatigorsk  possess 
warm  springs  of  a  similar  temperature;  but  the  patients  who 
come  to  Gastein,  who  are  frequently  advanced  in  years,  are 
emaciated,  with  failing  nutrition,  with  weak  nerves,  and  whose 
nervous  condition  and  nutrition  improve  so  well  under  the 
influence  of  the  mountainous,  cool  climate  and  pure  air  of  Gastein, 
would  fare  poorly  at  Pyatigorsk  with  its  hot  summer,  and  dusty 
and  malodorous  air ;  whereas  for  patients,  who  are  treated  by 
baths,  mercury  and  iodides,  and  who  therefore  are  easily  pre- 
disposed to  cold,  the  hot  summer  and  the  warm  soil  of  Pyati- 
gorsk are  very  suitable.*  Another  example:  it  is  a  quite  differ- 
ent thing  to  order  salt  baths  in  Stara  Russa  (in  the  Novgorod 

*  I  do  not  speak  here  of  the  peculiar  characteristics  of  the  water  of  the 
warm  Gastein  springs  to  conduct  an  electric  current,  as  proved  recently 
by  exact  physical  investigations,  because  the  nature  of  its  therapeutic 
value  (and  this  last  we  have  no  foundation  to  deny)  is  not  known  with 
certainty. 


—  343  — 

Government)  with  its  damp  and  cool  summer,  or  in  Slavyansk 
(in  the  Charkoff  Government)  with  its  dry  and  hot  summer 
or  at  the  Odessa  estuary,  where  the  summer  heat  is  modified  by 
the  influence  of  the  Black  Sea. 

Then  for  the  patient  who,  for  the  sake  of  a  trip  to  the  water- 
ing place,  leaves  his  habitual  surroundings,  his  usual  mode  of 
living  and  his  ordinary  diet,  the  degree  of  comfort  and  the 
conditions  of  life  at  this  place  are  of  no  small  importance :  one 
enjoys  a  quiet,  restful  locality,  rich  in  natural  beauties  ;  the 
other  is  more  benefited  by  a  great,  populous,  lively  centre,  as  the 
most  frequented  watering  places  become  during  the  "  season." 
Finally,  it  is  of  course  of  very  great  importance  as  to  what  sort 
of  a  physician  will  supervise  and  direct  the  treatment  at  the 
watering  place. 

The  above  is  sufficient  to  show  how  necessary  it  is  for  the 
physician  to  act  thoughtfully  not  only  when  he  advises  a  trip 
to  a  watering  place,  which  is  in  the  majority  of  cases  so  burden- 
some for  the  patient,  but  also  when  he  recommends  a  certain 
watering  place.  It  is  necessary  to  become  thoroughly  acquaint- 
ed with  such  places,  at  least  with  the  most  important  of  them, 
either  through  the  medium  of  literature,  or,  which  is  better,  by 
a  personal  visit.  As  a  summer  trip  with  the  purpose  of  resting 
or  of  travelling,  the  physician  will  find  nothing  more  pleasant 
than  a  trip  to  the  watering  places  for  a  personal  acquaintance 
with  them,  as  well  as  for  the  observation  and  treatment  of 
diseases,  the  sufferers  with  which  flock  thither.  The  watering 
places  form  a  sort  of  a  clinic  of  such  diseases. 

I  will  turn  now  to  the  further  examination  of  the  waters. 
.  2.  Salt  waters  (containing  common  salt).  —  Their  action  is  of 
a  double  nature  —  thermic  and  chemical ;  the  benefit  derived 
therefrom  is  apparent :  that  the  thermic  agency  may  by  itself 
exert  a  strong  effect  on  the  processes  of  metabolism  and  absorp- 
tion, we  must  have  a  recourse  either  to  hot  baths  —  31°  R. 
(101.8°  F.)  and  higher,  or  to  cold  ones  —  21°  B.  (79.2°  #.) 
and  lower,  for  which  the  majority  of  cases  will  present  contra- 
indications ;  the  addition  to  the  thermic  effect  of  a  chemical 
agency  —  the  common  salt  —  which  acts  in  the  same  manner  as 
the  thermic  one,  enables  us  to  confine  ourselves  in  such  cases 


—  344  — 

to  either  thermically  indifferent  baths,  28°  R.  (95°  i^,)  to 
27°  R.  (92.7°  F.\  or  to  warm,  29°  R.  (97.2°  F.)  to  30°  R. 
(99.5°  i^.),  or  to  cool  ones,  26°  R.  (90.5^.)  to  22°  R.  (81.5°  F.), 
and  it  certainly  increases  also  the  action  of  both  the  hot  and  the 
cold  baths.  The  percentage  of  common  salt  in  such  baths  is 
usually  from  two  to  four,  seldom  greater,  while  at  the  beginning, 
for  a  very  sensitive  skin  and  in  the  case  of  children,  it  is  even 
smaller,  beginning  with  one  per  cent.  The  chief  indications  for 
the  use  of  salt  baths  are  :  scrofula,  rickets,  chronic  exudations, 
chronic  multiple  arthritis  (chronic  articular  "rheumatism"),  less 
frequently  diseases  of  the  nervous  system.  The  salt  water  sprmgs 
are  very  abundant  in  Western  Europe ;  the  places  particularly 
frequented  are  Kreutznach,*  Wiesbaden,!  Soden,|  Ischl,§  Gmun- 
den,||  Reichenhall,^  and  others.  Of  our  springs  —  Stara  Russa, 
Slavyansk  and  the  Black  Sea  estuary  at  Odessa  (their  action, 
in  a  general  way,  is  similar  to  that  of  the  salt  springs). 

3.  Oarhonated  waters,  containing  a  great  quantity  of  free  car- 
bonic acid,  as  Schwalbach,**  or  our  Narzan  in  Kisslovodsk. 
These  are  used  in  the  form  of  cool  baths  ;  in  the  thermically  in- 
different, and  especially  in  the  warm  ones  the  carbonic  acid 
evaporates  rapidly.  The  effect  is  partly  of  a  thermic  nature,  but 
principally,  thanks  to  the  carbonic  acid,  strongly  stimulating. 
They  are  indicated  in  cases  of  neurasthenia  and  hysteria  (also 

*  In  the  Rhine  province,  situated  on  the  Nabe,  twenty-one  miles  west 
southwest  of  Maintz. 

t  In  Hesse-iSTassau,  Prussia,  three  miles  from  Rhine  and  six  miles  north 
by  west  of  Maintz.  It  was  known  in  Roman  times ;  is  frequented  annually 
by  about  ninety  thousand  visitors. 

I  In  Hesse-Nassau,  nine  miles  west  northwest  of  Frankfort  on  the 
Main. 

§  In  Upper  Austria,  at  the  junction  of  the  rivers  Ischl  and  Fraun, 
twenty-seven  miles  east  by  south  of  Salzburg.  It  is  the  favorite  resort  of 
the  Austrian  royal  family  and  nobility.  Population  in  1891  (commune), 
8,473. 

II  In  Upper  Austria,  situated  on  the  lake  of  Traun,  thirty-three  miles 
southwest  of  Linz. 

T[  In  Upper  Bavaria,  situated  on  the  Saalach,  nine  miles  southwest  of 
Salzburg. 

**  Or  Langenschwalbach  in  Hesse-Nassau,  Prussia,  eight  miles  north- 
west of  Wiesbaden.    Population  (1890),  2,698. 


—  345  — 

in  conjunction  with  chlorosis  and  anaemia)  with  the  character  of 
depression,  and  contraindicated  in  these  diseases  if  they  present 
the  character  of  excitement.  Thej  are  also  employed  after 
treatment  by  warm  and  hot  baths  to  remove  the  condition  of 
debility  and  the  predisposition  to  colds,  created  by  these  last, 
as  for  instance,  the  baths  of  Narzan  after  treatment  at  Pyati- 
gorsk. 

4.  Salt  ivaters  tvhieh  are  at  the  same  time  carbonated^  as  the 
artesian  springs  of  Rehme-Oeynhausen  in  Prussia.  Their  action 
is  of  a  complicated  nature,  —  thermical,  chemical,  and,  thanks 
to  the  carbonic  acid,  strongly  stimulating  to  the  nervous  system; 
their  employment  therefore  requires  particularly  careful  consid- 
eration :  empirically  they  are  recommended  in  diseases  of  the 
nervous  system,  especially  in  the  different  varieties  of  tabes 
dorsalis. 

5.  Mineral  muds,  added  to  baths  of  mineral  ivaters,  i.  e.  em- 
ployed in  the  form  of  dissolved  mud-baths,  are  employed  at  many 
foreign  watering  places ;  with  us  in  the  Pyatigorsk  group  of  min- 
eral waters  the  mud  of  the  lake  of  Tambuktan  is  employed  for 
diluted  mud-baths.  Franzensbad  has  been  particularly  famous 
for  a  long  time  for  its  moorbader.  To  what  was  already  said 
about  their  use  we  must  add  their  employment  in  diseases  of 
women,  in  which  they  are  very  frequently  applied.  The  effect 
of  the  Franzensbad  moor-baths  in  diseases  of  women  is  usu- 
ally explained  and  described  in  the  following  manner:  The 
mud-bath  causes  uterine  contractions,  these  being  the  more 
pronounced  in  proportion  to  the  state  of  flabbiness  and  enlarge- 
ment of  the  uterus.  Thus,  if  the  mud-baths  be  used  in  a  case  of 
insufficient  involution  of  the  uterus  soon  after  normal  delivery 
or  after  abortion,  then  the  identical  phenomena  are  observed  as 
accompany  in  the  normal  course  of  the  lying-in  period  the  pro- 
cess of  involution  of  the  uterus,  namely,  labor-like  sensations 
and  an  increased  secretion  resembling  lochia,  and  containing 
formative  elements  peculiar  to  this  last.  And  just  as  after- 
pains  cause  the  narrowing  and  obliteration  of  the  uterine  ves- 
sels, thus  weakening  the  nutrition  of  the  uterine  muscle  and 
bringing  about  the  transformation  of  its  albuminous  substances 
into    easily    absorbable    fats,   in    the    same    manner    the    con- 


^  346  — 

tractions  of  the  uterus  caused  by  the  mud-baths  determme  the 
identical  process  in  case  of  uterine  subinvolution.  If  as  a  result 
of  a  prolonged  state  of  subinvolution  of  the  uterus  its  mucous 
membrane  has  also  suffered,  then  a  prolonged  employment  of 
mud-baths  causes  a  return  to  the  normal  condition  not  only  of 
the  uterine  muscle,  but  also  of  its  mucous  membrane,  llie  ab- 
sorption of  exudations  in  the  parametrium  is  also  assisted  by  the 
use  of  the  baths  in  question.  The  drinking  of  the  waters  of 
Franzensbad  springs,  which  are  slightly  laxative  and  are  bene- 
ficial in  digestive  disturbances  to  which  these  women  are  usu- 
ally subjected,  assists  in  the  treatment  by  mud-baths. 

6.  The  mineral  muds  emijloyed  directly  as  such.  —  Those  of 
Saki,  spoken  of  above,  at  Tchocra,  near  Kertch,  at  Tinack,  near 
Astrachan.  The  foreign  physicians,  as  far  as  we  are  aware,  do 
not  employ  these  methods  of  treatment. 

7.  Sea-bathing.  —  The  effective  agencies  in  this  are  as  fol- 
lows : 

The  psychical  effect  of  the  sea-view,  especially  on  those  whose 
constant  residence  is  far  from  the  seashore,  is  usually  benefi- 
cial by  inducing  a  restful,  hearty  mental  state,  and  inspiring 
love  of  life  ;  other  beneficent  factors  are  :  the  salt  and  the  low 
temperature  of  the  sea- water  (usually  below  21°  7?. —  79.2°  F. — 
80  that  it  acts  like  a  cold  salt  bath)  ;  the  continuously  inter- 
changing effects  of  the  temperature  of  the  water  and  of  that  of 
the  air  as  the  body  is  either  wholly  or  partly  immersed  in  the 
water :  these  temperatures  are  usually  variable,  the  water  being 
fresher,  the  air  warmer,  and  on  the  contrary;  besides,  the  air  is 
usually  in  motion  (the  winds),  and  so  is  the  water,  which  fact 
tends  to  even  more  increase  the  variability  of  the  temperature ; 
and  a  changeable  temperature  stimulates  the  peripheral  nerves 
much  quicker  than  one  that  is  constant,  whether  it  be  low  or 
high  ;  considerable  mechanical  influences :  the  wind,  the  waves, 
the  motions  of  the  bather;  the  humid,  pure  air  of  the  seashore, 
which  is  under  the  greatest  atmospheric  pressure  and  conse- 
quently rich  in  oxygen. 

It  is  evident  from  the  above,  that  the  effect  of  sea-bathing  is 
very  pronounced  on  the  nervous  system  as  well  as  on  nutrition 
(as  the  appetite  is  very  much  increased  by  it,  sea-bathing  is  con- 


—  347  — 

traindicated  for  patients  with  poor  digestive  powers).  Sea- 
bathing is  recommended  principally  for  cases  of  neurasthenia 
and  hysteria  with  the  character  of  depression,  and  contraindi- 
cated  in  the  same  affections  with  the  character  of  excitement. 
For  the  indications  and  contraindications  to  sea-bathing  in  the 
colder  climates  (in  the  Baltic  Sea,  Northern  Sea,  and  LaManche) 
and  in  the  warmer  (Bay  of  Biscay,  Mediterranean,  Black  and 
Caspian  Seas)  compare  below,  in  the  treatment  of  diseases  of 
the  nervous  system,  the  general  indications  and  contraindica- 
tions to  cold  and  warm  baths.  Sea-bathing  is  also  recommended 
after  treatment  with  the  warm  and  hot  baths  to  remove  the 
weakness  and  predisposition  to  cold  created  by  them;  thus  after 
treatment  with  the  Saki  mud-baths,  the  patients  are  recommended 
sea-bathing,  for  which  purpose  is  very  suitable  the  seashore 
near  Eupatoria  (in  the  Crimea)  with  its  warm  water  and  warm 
air  during  the  summer.  Sea-bathing  is  also  sometimes  pre- 
scribed for  suitable  cases  of  scrofula  in  place  of  salt  baths  ;  and 
also  in  some  certain  cases  of  superfluous  fat  or  general  obesity. 

I  will  say  a  few  words  on  some  other  varieties  of  baths.  Tlie 
hot-air  baths.  Their  strong  effect  was  sufficiently  explained  in 
the  analysis  of  the  sixteenth  case  of  chronic  parenchymatous 
nephritis. 

Fir-tree  baths.  —  These  are  prepared  by  adding  to  baths  of 
plain  or  mineral  water  a  distillation  by  steam  of  pine  and  fir  nee- 
dles, containing  ethereal  oils,  and  a  decoction  of  these  last  con- 
taining tar,  turpentine  and  organic  acids.  The  effect  is  that  of 
a  stimulant.  The  electric  baths,  together  with  the  other  methods 
of  applying  electricity,  are  discussed  with  the  subject  of  electro- 
therapy. 

8.  Hydrotherapy.  —  All  the  hydrotherapeutic  procedures  are 
generally  applied  in  such  a  manner,  that  the  patient  becomes  at 
first  chilled,  and  is  later  on  warmed  or,  in  view  of  the  fact  that 
the  cooling  of  the  body  acts  the  stronger  the  warmer  the  body 
before  the  cooling  began,  he  is  at  first  warmed  up,  then  chilled, 
and  later  is  warmed  up  finally.  This  final  warming  up  is  known 
as  the  reaction.  For  the  treatment  to  succeed,  the  reaction 
must  be  complete :  if  it  be  absent  or  incomplete,  a  condition 
similar  to  fever  ensues,  and  in  case  the  hydrotherapeutic  proce- 


—  348  — 

dures  are  frequently  repeated  without  any  reaction  following 
them,  a  genuine  febrile  condition  is  developed  which  continues 
also  after  the  cessation  of  the  hydrotherapeutic  treatment,  and 
which  debilitates  the  patient,  as  was  explained  already  in  con- 
nection with  the  effects  of  cold  baths.  I  will  state  here  that 
the  same  may  occur  to  the  patient  also  while  bathing  in  the  sea 
or  anywhere  else,  if  the  bather  remains  in  the  water  for  a  long 
time  ;  therefore,  having  become  chilled  on  immersing  in  the 
water  and  warmed  up  later,  the  bather  must  emerge  from  his 
bath  while  he  is  warmed,  before  secondary  chilling  takes  place. 

The  hydrotherapeutic  procedures  act  both  thermically  and 
mechanically ;  their  effect  is  ver}-  strong,  especially  on  the  ner- 
vous system.  They  are  principally  recommended  for  diseases 
of  the  nervous  system,  particularly  for  neurasthenia  and  hys- 
teria ;  they  are  also  recommended  for  the  removal  of  the  predis- 
position to  colds,  for  superfluous  fat  and  in  some  other  cases. 

The  hydrotherapeutic  procedures,  namely,  the  various  forms 
in  which  hydrotherapy  is  applied,  are  general  and  local. 

Of  the  general  forms  the  best  is  the  fan-like  douche  under  a 
high  pressure.  The  construction  of  such  a  douche  enables  one 
to  change  the  temperature  of  the  water  rapidly,  almost  instantly, 
and  therefore  not  only  can  the  patient  be  first  warmed  up  and 
then  cooled  off,  but  this  process  can  be  repeated  as  many  times 
as  necessary.  The  form  of  the  water  as  it  strikes  the  body  in 
spurts  increases  the  stimulating  effect  of  the  douches.  Finally, 
the  water  strikes  the  body  with  a  force  which  the  construction 
of  the  douche  permits  of  varying  and  causing  it  to  become,  if 
necessary,  very  considerable.  Consequently  such  a  douche 
exerts  simultaneously  both  a  thermic  and  a  mechanical  effect, 
whereas  in  the  other  most  frequently  applied  procedures,  as 
rubbings  and  half-baths,  a  mechanical  effect  is  brought  about  by 
the  aid  of  massage,  i.  e.  by  the  assistance  of  a  very  skillful  ma- 
nipulator. The  douche  is  directed  all  over  the  body,  from  below 
upward  and  backward,  except  on  the  head.*     The  antiquated 

*  (Addition  to  the  first  edition.)  All  that  was  said  of  the  fan-like  douche 
refers  to  cool  and  cold-water  douches.  In  some  cases  hot-water  douches 
are  very  beneficial  :  local,  from  35°  B.  (110.8°  F.)  to  40°  E.  (122°  F.),  in 
the  form  of  a  single  stream,  most  frequently  in  obstinate  "  rhevimatic  " 
affections  (usually  arthritis  and  neuritis,  less    frequently    myositis     of 


—  349  — 

douches  which  are  unfortunately  not  dismissed  as  yet  by  lay- 
men, in  which  the  principal  mass  of  the  spurting  water  strikes 
the  head,  are  very  harmful. 

Of  the  other  general  procedures  the  most  used  and  undoubted- 
ly effective  and  beneficial  ones  are  the  rubbings  and  the  half- 
baths.  At  times,  to  be  sure  in  but  rare  cases,  they  are  borne 
better  than  the  fan-like  douche  under  high  pressure,  although 
the  majority  of  patients  express  a  preference  for  the  latter. 

Of  the  local  forms  of  applying  hydrotherapy  the  most  fre- 
quently used  ones  are :  cooling  of  the  head,  in  hyperaemia  of 
the  brain,  heat  to  it  in  ansemia  of  the  brain,  watery  clysters,  a 
warming  compress,  etc. 

9.  It  is  evident  from  the  above-outlined  sketch  that  it  is  not 
necessary  for  balneotherapeutic  treatment  always,  in  every  case, 
to  send  the  patient  away  to  a  watering  place,  to  the  seashore, 
or  to  some  large  city  with  a  well  constructed  hydrotherapeutic 
institution.  The  most  important  varieties  of  baths,  baths  of 
variable  temperatures  and  salt  baths,  at  times  with  the  addition 
of  soda,  may  be  prescribed  and  carried  out  with  the  necessary 
implements  at  the  patient's  residence.  Sea-bathing  may  be  re- 
placed by  bathing  in  the  river  or  in  a  lake.  Hydrotherapeutic 
rubbings  and  half-baths  may  be  carried  out  everywhere  by  in- 
structing a  servant  how  to  do  it.  For  the  fan-like  douches 
there  are  portable  apparatuses,  which  give  a  sufficiently  high 
pressure,  thus  :  the  portable  douches  of  Piet  and  the  much 
cheaper  pumps  of  Allweiler,  which  are  conveniently  affixed  to 
the  douches. 

I  must  say  here  a  few  words  concerning  the  use  of  our  popu- 
lar bath  (Russian  bath) .  Its  hygieniQ  value,  as  evidenced  by 
its  purifying  the  skin,  removing  the  fats  and  dirt  which  ob- 
struct the  glands  of  the  skin,  and  by  keeping  up  the  normal 
functional  activity  of  the  skin,  is  very  great,  and  especially  so 
for  the  laboring  class  of  the  community ;  but  its  employment 

gouty,  syphilitic,  catarrhal,  traumatic  and  other  origin)  in  persons  unable 
to  bear  cold  —  usually  in  conjunction  with  massage  (and,  if  necessary, 
with  the  contemporaneous  treatment  of  the  gout  and  the  syphilis),  and 
also  in  diseases  of  women  ;  general,  from  33°  R.  (106.2°  F.)  to  38°  B. 
(117.2°  F.),  in  the  form  of  a  fan-like  douche  under  high  pressure,  for  neu- 
rasthenia and  hysteria  in  debilitated,  aneemic  and  chilly  persons. 


—  350  — 

during  the  cold  season  of  the  year,  in  bad  weather,  entails  the 
risk  of  catching  cold  on  returning  from  the  bath-house.  With- 
out therefore  dissuading  healthy  people  habituated  to  it  from 
employing  it,  and  advising  only  to  avoid  hot  baths  and  bathing 
during  bad  weather,  I  must  say  that  the  use  of  these  baths 
must  be  strictly  limited,  or  even  prohibited,  to  persons  who  are 
weakly  and  predisposed  to  colds,  the  more  so  to  ailing  ones. 
The  therapeutic  effect  of  the  bath  and  of  the  usual  massage  con- 
nected therewith,  in  cases  of  slight  ailments  due  to  a  cold,  but 
of  a  "  rheumatic  "  and  not  of  a  catarrhal  origin,  is  beyond 
doubt  beneficial,  but  during  the  cold  season  of  the  year  and  in 
bad  weather  it  is  accompanied  by  considerable  risks. 

Balneotherapeutic  procedures  employed  in  a  warm  room 
may  be  applied  during  all  the  seasons  of  the  year ;  but  the 
best  season  for  such  treatment  is  certainly  the  warm  one, 
when  a  prolonged  stay  out-doors  is  possible  without  risking  a 
cold.  As  regards  the  time  of  the  day,  all  the  balneotherapeu- 
tic applications  must  be  made  not  on  an  empty  stomach,  but 
best  after  the  morning  coffee  or  tea,  after  a  previous  evacuation 
of  bowels. 

The  duration  of  the  balneotherapeutic  course  of  treatment 
depends  certainly  on  the  peculiarities  of  the  given  case,  but  in 
the  majority  of  cases  it  does  not  require  more  than  one  and  a 
half  or  two  months.  An  unnecessarily  prolonged  hydrothera- 
peutic  treatment  (and  I  have  seen  it  prolonged  not  only  over 
half  a  year,  but  even  over  one  or  two  years)  is  much  oftener 
harmful  than  beneficial,  by  debilitating  the  nutrition  and  the 
condition  of  the  nervous  system,  and  by  inculcating  in  the  pa- 
tients habits  of  constant  artificial  stimulation  by  the  aid  of 
hydrotherapeutic  procedures,  of  which,  later  on,  they  can  but 
with  difficulty  rid  themselves. 

A  short  outline  of  the  diseases  in  which  the  waters  are  used  ex- 
ternally^ will  give  you  some  idea  of  the  extent  of  balneothera- 
peutic applications  and  of  the  importance  of  this  method  of 
treatment. 

1.  Diseases  oftlie  nervous  system.  —  In  neurasthenia  and  hysteria 
with  their  multiform  manifestations  balneotherapy  is  consid- 
ered to  be  the  most  important  method  of  treatment,  both  on  ac- 


—  351  — 

count  of  the  effectiveness  of  its  action  and  the  variability  and 
extent  of  its  application.  The  chief  rule  to  be  observed  here 
is  as  follows :  in  proportion  as  we  have  a  young  patient  with  a 
strong  constitution,  in  whom  the  condition  of  the  internal  organs 
need  excite  no  apprehension,  whose  nutrition  is  good,  and  in 
whom  the  nervous  disturbances  bear  the  character  of  debility, 
the  more  suitable  it  is  to  use  cool  and  cold  water,  such  as  con- 
tains a  large  proportion  of  carbonic  acid,  and  the  balneothera- 
peutic forms  of  application  of  a  stimulating  nature,  as  douches, 
sponging,  half -baths,  sea-bathing  ;  all  these  necessitating  motion 
of  the  water,  movements  on  the  part  of  the  patient  and  massage. 
On  the  contrary,  if  our  patient  is  older,  possessing  a  weak  con- 
stitution, in  whom  the  condition  of  one  or  another  of  internal 
organs  excites  grave  apprehensions,  while  his  nutrition  is  poor 
and  the  nervous  disturbances  have  the  character  of  excitability, 
the  more  suitable  are  thermically  indifferent  waters  and  balneo- 
therapeutic applications  of  a  quieting  nature,  such  as  do  not 
necessitate  any  movement  either  on  the  part  of  the  patient  or  of 
the  water,  namely,  baths. 

But  this  rule  is  only  applicable  to  the  majority  of  cases  ;  in 
the  considerable  minority,  in  which  the  above-enumerated  con- 
ditions do  not  coincide  (as,  for  instance,  when  the  patient  is 
young,  but  weak  constitutionally,  or  young,  of  a  strong  consti- 
tution, but  emaciated,  debilitated  and  chilly,  and  so  on ;  or  the 
patient  is  not  young,  but  of  a  strong  constitution  and  nutrition, 
while  his  nervous  disturbances  have  the  character  of  debility 
etc.),  after  inquiring  carefully  of  the  patient  as  to  the  former 
effect  on  him  of  a  cold  and  a  warm  bath  (as  bathing  outside 
and  indoors,  warm  baths),  we  must  act  in  a  manner  reverse  to 
this  rule.  Finally,  there  may  occur  cases  which  present  no 
positive  indications  for  either  of  the  methods  and  m  which  a 
careful  trial  will  determine  the  method  to  be  resorted  to. 

Diseases  of  the  brain,  principally  disturbances  of  the  circula- 
tion as  determined  by  a  condition  of  atheromatosis  of  the  arte- 
ries (general  and  those  of  the  brain  in  particular)  and  by  other 
causes.  For  these  the  chemically  and  thermically  indifferent 
baths  are  suitable ;  at  times  also  the  warm  ones  (not  over  29°  M.  — 
97.2°  #.)  and  the  slightly  alkaline,  namely,  those  containing  but 


—  352  — 

a  small  quantitj-  of  sodium  chloride  and  of  soda,  and  also  cooling 
of  the  head  (in  some  cases  warming  it) ;  cold  and  hot  baths,  as 
well  as  the  applications  tending  to  stimulation,  are  contraindi- 
cated. 

Diseases  of  the  spinal  corcl^  principally  tabes.  For  these  the 
thermically  indifferent,  salt  and  salt-gaseous  (with  a  moderate 
quantity  of  common  salt  and  carbonic  acid)  baths  are  suitable, 
as  well  as  slight  hydrotherapy  (sponging).  Hot  and  cold  baths, 
baths  containing  great  quantities  of  salt  and  carbonic  acid, 
as  well  as  strongly  stimulating  forms  of  application,  as  douches 
and  sea-bathing,  are  contraindicated. 

2.  Diseases  of  the  digestive  organs.  —  For  gastro-intestinal 
neurasthenia,  which  is  expressed  in  a  weakened  condition  of 
the  nervo-muscular  apparatus  of  the  intestines  and  stomach, 
various  douches,  cool,  cold,  and  of  changeable  temperature,  or 
a  warming  compress  on  the  abdomen,  in  connection  of  course 
with  simultaneous  general  hydrotherapy  for  the  general  neuras- 
thenic condition,  are  very  beneficial.  In  catarrhal  conditions  of 
the  stomach,  intestines  and  the  biliary  passages,  as  well  as  in 
biliary  calculi,  warm  baths  form  an  excellent  adjunct  to  the 
ordinary  treatment  of  these  diseases. 

3.  Warm  baths  are  equally  beneficial  for  renal  gravel,  for 
pyelitis,  catarrh  of  the  ureters  and  the  urinary  hladder,  while  cases 
of  acute  and  chronic  7iephritis  are  benefited  also  by  hot  baths. 

4.  For  hyperoimia  of  the  spleen  douches  over  the  left  hypo- 
chondrium,  of  the  same  nature  as  those  employed  in  gastro-in- 
testinal neurasthenia. 

5.  Different  varieties  of  peritoneal  inflammation.  —  Some  pa- 
tients bear  ice  better,  others  warm  applications,  others  again  a 
warming  compress  on  the  abdomen. 

6.  Diseases  of  the  male  genital  organs,  principally  the  various 
forms  of  impotentia  virilis.  In  these  the  general  balneothera- 
peutic treatment,  directed  against  the  general  neurasthenic  con- 
dition, is  of  more  importance  than  the  local  treatment ;  while 
locally,  after  the  general  neurasthenia  has  been  removed,  care- 
ful electrotherapy  is  particularly  efficacious. 

7.  Diseases  of  the  female  genital  orgatis.  —  We  spoke  of  the 
peritoneal    inflammations    above.     For  painful  menstruation  a 


—  353  — 

rubber  bag  filled  with  hot  water  and  applied  to  the  lower  part 
of  the  abdomen  is  beneficial.  For  light  cases  of  metritis,  warm 
sitz-baths.  For  subinvolution  of  the  uterus  and  the  endometri- 
tis dependent  thereon,  and  also  for  exudations  in  parametrium, 
the  thermically  indifferent,  salty  and  moor  baths  and  hot  vagmal 
injections  are  useful. 

8.  Diseases  of  the  resjnratori/  organs.  —  The  inhalation  of  va- 
rious atomized  liquids  for  catarrhal  conditions  of  the  larynx 
and  trachea.  Hot  baths  followed  by  sweating  in  bed  while  cov- 
ered by  warm  blankets  are  at  times  resorted  to  in  cases  of 
bronchial  catarrh  accompanied  by  very  abundant  secretions,  for 
the  sake  of  alternating  with  other  methods  of  treatment,  if  the 
patient  became  so  habituated  to  these  last  that  they  fail  to  ex- 
ert any  marked  effect  on  him ;  these  baths  may  be  employed 
only  when  the  condition  of  the  heart  permits  it,  and  generally 
extreme  care  must  be  exercised.  In  pleuritis  and  in  pleuropneu- 
monitis,  a  warming  compress  applied  over  the  affected  part  of 
the  chest  is  beneficial ;  however,  in  the  majority  of  cases  the  pa- 
tients prefer  better  to  keep  this  part  warm  by  the  aid  of  warmed 
oil,  cotton-batting  and  flannel.  In  chronic  pulmonary  tubercu- 
losis the  patients,  if  not  feverish,  at  times  bear  well  the  some- 
what cool  sponging  prescribed  with  a  view  of  assisting  the  func- 
tion of  the  skin  and  simultaneously  combating  the  neurasthenic 
condition. 

9.  Diseases  of  the  heart,  —  Neuroses  of  the  heart  —  palpitation, 
cardiac  asthma,  angina  of  nervous  character  (not  the  true  angina 
pectoris  coronaria),  as  well  as  the  cardiac,  angioneurotic  and 
other  neurotic'  conditions  associated  with  morbus  Basedowi,  as 
well  as  the  weakness  of  the  cardiac  muscle  determined  by  it,  as  evi- 
denced by  a  dilated  heart  and  a  weak  pulse,  —  all  these  present 
indications  for  the  employment  of  balneotherapeutic  treatment, 
the  nature  of  which  depends  on  the  character  of  the  general 
nervous  condition  present  and  of  all  the  peculiarities  of  the  given 
case  (vide  above  concerning  balneotherapy  in  neurasthenia  and 
hysteria)  ;  this  treatment  is  indicated  not  only  when  the  heart 
and  the  arteries  are  in  a  normal  condition,  but  even  when  they  pre- 
sent incipient  organic  alterations  ;  extreme  caution  is  certainly  to 
be  exercised  in  these  cases,  and  the  treatment  is  to  be  instituted 


—  354  — 

only  when  there  exists  a  complete  compensation  of  the  organic 
disturbances. 

10.  Diseases  of  nutrition  and  luematopoiesis.  —  Chlorosis  and 
ansemia  accompanied  by  their  usual  neurasthenic  and  hj-sterical 
symptoms,  present  indications,  in  slight  cases,  for  the  use  of 
warm  sea  or  river  bathing  —  20°  R.  (11°  F.^  to  18°  R.  (72.5° 
jP.)  —  and  also  of  slightly  carbonated  baths  ;  for  more  pronounced 
cases  plain  or  salty,  thermically  indifferent  baths,  while  for  strong- 
ly pronounced  ones  balneotherapeutic  treatment  is  contraindi- 
cated.  For  general  obesity  cool  salt  baths  and  river  and  sea 
bathing  are  suitable.  For  diabetes  mellitus,  which  is  etiologi- 
cally  so  closely  connected  with  the  nervous  system,  thermically 
indifferent  and  slightly  cooling  spongings  are  indicated  in  accord 
with  the  condition  of  this  last.  For  gout  thermically  indiffer- 
ent baths;  of  these  the  best  are  salty,  alkalme  ones. 

11.  For  scrofulosis.  —  Thermically  mdifferent  and  cool  salt 
baths,  and  sea-bathing. 

1 2.  For  sy])hilis.  —  Warm  baths  to  assist  cleanliness  and  the 
functional  activity  of  the  skin  (which  in  its  turn  aids  in  the 
better  absorption  of  the  mercury),  and  hot  baths  to  enhance 
the  activity  of  the  metabolic  processes,  usually  given  simultane- 
ously with  the  administration  of  the  specific  treatment ;  later  on, 
to  remove  the  debility  and  the  predisposition  to  colds  engendered 
by  such  treatment,  strong  carbonated  baths  (Xarzan  after  Pyati- 
gorsk), sea-bathing  and  hydrotherapy  are  resorted  to. 

13.  In  metallic  poisoning,  most  frequently  in  mercury  and 
lead  poisoning,  hot  baths  and  later  strengthening  balneothera- 
peutic procedures  are  also  used. 

14.  What  concerns  the  application  of  balneotherapeutic  pro- 
cedures for  febrile  conditions  and  febrile  affections  it  was  spoken 
of  and  discussed  by  me  in  connection  with  the  several  analyzed 
cases. 

15.  Diseases  of  the  skin  and  of  the  subjacent  tissues.  —  Cold 
fomentations  and  ice  in  traumata,  hypersemia  and  inflammations. 
Baths  with  alkaline  carbonates  and  sulphates  for  certain  erup- 
tions. 

16.  Chronic  myosites,  neurites  (most  frequently  ischias)  and 
arthrites,    as   multiple   chronic   arthritis   and  chronic  articular 


—   355  — 

"  rheumatism."  For  these  are  suitable  warm  and  hot,  salt  and 
alkaline  baths,  as  well  as  the  muds,  and  later,  to  strengthen  the 
patient  who  became  weak  from  the  treatment  and  to  remove  the 
predisposition  to  cold,  strongly  carbonated  baths,  warm  sea- 
bathing, as  in  Eupatoria  after  treatment  by  the  Saki  muds,  and 
careful  hydropath}".  1  must  note  the  following :  Strange  as  it 
may  seem,  I  have  often  observed  that  treatment  of  "  catarrhal" 
diseases,  namely,  of  the  above-named  chronic  affections  of  the 
organs  of  locomotion  and  also  catarrhal  conditions  of  the  res- 
piratory and  other  passages,  is  often  confounded  with  the 
treatment  of  an  existing  predisposition  to  colds.  Thus  the  pa- 
tient tells  his  physician,  that  he  has  "■  rheumatics"  and  is  fre- 
quently subjected  to  colds,  although  he  suffers  from  none  at 
the  present  time.  The  physician  catches  at  the  word  '•  rheu- 
matics," prescribes  warm  or  even  hot  baths,  plain  or  salty  ones  (I 
had  occasion  to  see  the  Saki  mud  advised  in  view  only  of  a  pre- 
disposition to  cold,  without  any  cold  or  '^  rheumatic"  affection 
being  present  at  the  time  of  the  advice),  which  certainly  only 
tend  to  increase  this  predisposition.  This  last  condition  must 
be  treated  not  by  hot  baths  and  muds,  but  by  removing  its  causa- 
tive agencies,  which  are  usually  found  to  lie  in  gout,  syphilis, 
abuse  of  alcoholic  drinks,  in  a  habit  for  abundant  hot  drinks 
and  warm  clothing,  in  neurasthenia,  etc. ;  while  for  the  treat- 
ment of  neurasthenia  and  at  the  same  time  to  inure  the  body  to 
cold,  hydrotherapy  and  bathing  are  suitable,  and  certainly  not 
hot  baths  or  muds. 


CHOLERA,  PARTICULARLY  ITS 
TREATMENT. 


LECTURE  OF  MARCH   19,  1893. 

Whether  or  not  we  shall  be  visited  by  cholera  this  year  is  un- 
certain. The  history  of  the  past  presents  no  positive  precedents 
in  this  regard.  Durmg  the  summer  of  1883  Egypt  was  visited 
by  a  very  severe  epidemic  of  cholera,  the  one  during  which 
Koch  succeeded  in  finding  the  cholera  bacillus,  while  the  sum- 
mer of  the  following  year  in  Egypt  was  perfectly  free  from  it. 

But  it  is  certainly  probable  that  we  may  also  have  an  epi- 
demic this  present  year.  It  is  true  that  cholera,  which  remained 
over  winter  and  came  to  life  again  in  the  given  locality,  may 
not  possess  the  same  virulence  nor  be  diffused  so  extensively 
as  when  carried  over  from  another  locality ;  but  still  it  is  pos- 
sible that  many  of  you  will  have  to  face  the  necessity  of  com- 
bating this  disease,  and  I  therefore  consider  it  my  duty,  the 
duty  of  a  clinician,  to  assist  you  as  far  as  it  lies  in  my  power 
by  my  advice. 

Cholera,  as  many  other  diseases,  is  familiar  to  you  from  the 
systematic  course  of  special  pathology;  but  firstly,  this  course 
you  attended  a  year  or  more  ago,  and  science  never  remains  in 
one  place ;  it  is  never  stationary  :  its  level  is  becoming  contin- 
uously higher  and  higher  and  is,  besides,  constantly  changing, 
presenting  not  a  smooth,  but  a  constantly  undulating  surface  : 
one  point  falls,  the  other  rises  to  the  surface.  The  year  just 
passed,  a  year  of  a  consideral^le  cholera  epidemic,  was  particularly 
instrumental  in  compelling  us  to  revise  our  knowledge  concern- 
ing cholera  and  especially  its  treatment.  It  is  therefore  imperative 
that  you  become  acquainted  with  the  results  of  this  revision.  But 
it  chiefly  devolves  on  the  clinician,  in  view  of  a  possible  epidemic, 
356 


—  357  — 

to  discuss  the  subject  of  cholera  before  his  students  for  another 
reason.  After  attending  on  your  course  of  special  pathology, 
you  meet  later  in  the  clinics  all  the  forms  of  diseased  conditions 
peculiar  to  our  local  and  climatic  conditions  of  life ;  but  or- 
dinarily you  do  not  chance  across  cases  of  cholera.  For  the  long 
period  of  my  clinical  activity,  only  once,  in  the  sixties,  when  to 
my  clinic  was  annexed  a  department  for  cholera,  did  I  have  the 
opportunity  to  discuss  cholera  cases  before  the  students.  But 
ordinarily,  either  there  are  no  cases  of  cholera  during  the  aca- 
demic year,  or,  as  it  happened  last  year,  during  the  epidemic 
the  senior  students  of  the  last  year  are  absent,  having  been  sent 
away  to  combat  the  invasion  of  the  disease.  But  the  syste- 
matic course  of  special  pathology  cannot  educate  a  physician 
without  the  aid  of  the  clinic :  the  information  obtained  from 
this  course,  the  therapy  (not  to  speak  of  its  other  peculiarities) 
are  of  but  an  approximate  nature,  and  only  by  individualizing 
this  information,  applying  it  to  all  the  peculiarities  of  the  given 
case,  as  taught  by  the  clinic,  can  we  hope  for  a  successful  treat- 
ment. As  regards  cholera  it  is  the  duty  of  the  clinician  to  as- 
sist as  much  as  possible  in  what  the  clinic  is  lacking,  paying 
particular  attention  to  treatment,  to  discuss  as  far  as  the  lack 
of  clinical  individualization  will  permit,  at  least  the  principal 
forms  of  the  disease,  which  may  l)e  seen  in  patients  and  which 
may  require  treatment. 

The  object  and  character  of  my  lecture  is  thus  determined 
by  what  I  have  said  above.  The  question  of  the  nature  of 
cholera,  and  also  the  picture  of  the  disease,  will  be  touched 
by  me  only  so  far  as  may  become  necessary  for  elucidating  the 
prophylaxis  and  the  therapy. 

The  Nature  of  Cholera. 

Cholera  belongs  to  the  class  of  infectious  diseases.  These 
diseases  are  at  the  present  time  considered  to  be  caused  by  mi- 
cro-organisms, by  microbes  which  invade  the  organism  and  pro- 
duce the  diseased  condition  therein.  The  microbes  of  all  the 
infectious  diseases  have  not  as  yet  been  discovered,  but  the  very 
marked  similarity,  in  their  chief  features,  of  those  diseases  the 


—  358  — 

microbes  of  which  have  not  been  identified,  with  those  where 
these  have  been  found,  compels  us  to  class  both  varieties  under 
one  category. 

It  is  not  long  since  there  prevailed  a  classification  of  infec- 
tious diseases  into  miasmatic,  contagious,  and  miasatic-conta- 
gious. 

By  the  miasmatic  diseases  were  meant  such  as  are  not  trans- 
mitted from  one  infected  by  them,  to  another,  and  the  cause  of 
which,  the  pathogenic  microbes,  enter  the  affected  organism 
from  the  surrounding  elements.  The  malarial  diseases  were 
considered  as  tj^pes  of  such  affections. 

As  contagious  diseases  were  considered  such  as  are  capable 
of  being  transmitted  from  one  patient  to  another  in  a  direct 
manner,  without  the  participation  of  the  surrounding  nature. 
Among  these  were  classified  :  syphilis,  small-pox,  measles,  scarla- 
tina, typhus  fever,  diphtheria,  etc. 

By  miasmatic-contagious  diseases  were  meant  those,  which,  to 
become  infectious,  need  the  assistance,  so  to  speak,  of  the  sur- 
rounding elements  and  the  presence  therein  of  some  special 
favorable  conditions,  without  which  the  person  affected  by  this 
disease  within  the  given  locality  is  incapable  of  causing  an 
epidemic  ;  and  on  the  other  hand,  the  above-named  diseases  will 
not  develop  m  the  given  locality,  notwithstanding  the  presence 
in  the  surrounding  elements  of  all  the  conditions  favorable  for 
their  development,  as  long  as  this  locality  is  not  visited  by  a 
person  who  carries  within  his  system  the  germs  of  the  disease. 

It  was  therefore  assumed,  that  these,  after  leaving  the  pa- 
tient's organism,  are  not  yet  capable  of  causing  infection,  but 
become  so  after  remaining  under  favorable  conditions  for  a  cer- 
tain time  outside  of  the  organism.  To  this  class  of  diseases 
belong  cholera,  typhoid  fever,  etc. 

At  the  present  time  it  is  impossible  to  entirely  rely  upon  the 
classification  just  outlined :  successful  experiments  have  been 
made,  though  it  is  true  that  they  need  further  confirmation, 
of  inoculation  with  the  malarial  diseases  directly  from  the  pa- 
tient to  a  healthy  individual ;  syphilis  can  be  transmitted  not 
only  directly,  but  also  through  the  medium  of  dishes,  instru- 
ments, etc.,  consequently    after  it  has  remained  for  a   certain 


—  359  — 

time  under  the  influence  of  the  .surrounding  nature  :  the  same  is 
true  also  of  diphtheria.  It  seems  that  at  certain  times,  rare 
though  such  cases  may  be,  cholera  causes  a  direct  infection. 
Nevertheless,  the  principal  characteristic  peculiarities  of  the 
different  classes  of  infectious  diseases,  as  outlined  above,  do 
exist  and  are  to  be  kept  constantly  in  mind :  malaria  is,  after 
all,  non-contagious  outside  of  experimentation,  and  syphilis, 
measles,  small-pox,  scarlatina,  .typhus  fever,  diphtheria  are  of 
an  extremely  contagious  nature  ;  while  cholera  is  but  slightly  con- 
tagious and,  in  direct  contradistmction  to  the  very  contagious 
diseases,  it  depends  for  its  development  entirely  on  the  con- 
ditions present  in  the  surrounding  nature. 

Outside  of  the  "  seed"  of  the  disease  and  the  conditions  of 
the  surroundings,  an  important  role  m  infection,  as  proved  by 
observation,  is  played  by  the  individual's  predisposition  to  chol- 
era, or  by  the  absence  of  the  same. 

I  will  take  a  brief  survey  of  our  knowledge  concerning  the 
three  factors  which  play  the  chief  role  m  the  development  of 
the  cholera  epidemics. 

The  individual  predisposition  to  cholera  has  been  shown  by 
observation  to  be  determined  hj  digestive  disturbances  and  by 
failure  in  nutrition,  as  evidenced  by  the  fact  that  a  population 
exhausted  by  starvation  falls  an  easy  prey  to  the  epidemic. 
It  is  hardly  probable  that  this  fact  is  the  only  one  determinmg 
the  individual's  susceptibility  to  cholera,  but  we  know  nothing 
more  definite  about  the  subject. 

It  was  Pettenkofer  who  called  particular  attention  to  the 
conditions  of  the  surrounding  elements,  the  local  (meaning  the 
soil  and  climate)  and  the  temporary,  the  season  of  the  year  and  the 
condition  of  the  weather;  but  we  know  nothing  positive  regarding 
this  matter  :  thus,  for  instance,  Pettenkofer's  theories  concerning 
the  influences  of  the  vacillations  of  the  soil- water  on  the  develop- 
ment of  the  cholera  epidemics  have  not  been  substantiated  by 
facts.  As  an  example  of  the  prevalent  idea  as  touching  on  the 
influence  of  the  surroundings  on  the  development  of  cholera 
epidemics,  I  will  present  before  you  the  results  of  the  ob- 
servations and  mvestigations  made  by  the  well-known  bacteriol- 
ogist, Prof.  Hueppe,  during  the  recently  prevalent  severe  epi- 


—  360  — 

demic  at  Hamburg.*  I  shall  have  yet  another  occasion  to 
touch  upon  Prof,  Hueppe's  statements ;  and  I  will  therefore 
only  say,  as  far  as  they  are  concerned,  that  notwithstanding 
their  interest,  the  facts  presented  lack  verification,  while  the 
hypotheses  propounded  must  be  proved  by  facts. 

After  analyzing  the  local  conditions,  Hueppe  considers  as  the 
cause  of  the  sudden  and  very  severe  breaking  out  of  the  cholera 
epidemic  in  Hamburg  not  the  conditions  in  the  soil,  but  the 
condition  of  the  Hamburg  aqueduct.  The  water  is  derived 
from  the  Elbe,  above  the  city,  while  the  city  impurities  are 
conducted  into  the  Elbe  below  the  city  ;  during  the  high  tide 
of  the  sea,  these  last  are  carried  up  the  river  and  reach  the  place 
from  which  the  aqueduct  starts,  without  passing  through  any 
purifying  filter.  According  to  Hueppe,  the  cholera  was  im- 
ported into  Hamburg  from  Russia  or  France  on  sailing  vessels 
by  patients  whose  evacuations,  without  any  previous  disinfection, 
polluted  the  river.  As  a  general  fact,  Hueppe  assumes,  basing 
this  assumption  on  his  own  investigations  and  that  of  others, 
as  Frankel,  that  the  cholera  bacilli  are  rapidly  destroyed  in  the 
rivers  of  Europe  (although  this  is  somewhat  contradicted  by 
investigations  of  other  bacteriologists),  and  that  if  cholera  spreads 
along  the  course  of  rivers,  it  does  so  not  by  the  aid  of  the  cholera 
bacilli  carried  by  the  waters,  but  through  cholera  patients  sailing 
on  river  vessels  ;  but  he  points  out  that  during  the  month  of 
August,  1892,  when  the  Hamburg  epidemic  began,  there  were 
exceptional  conditions,  as  extreme  heat,  shoaliness  of  the  river 
and  the  warm  temperature  of  the  water,  which  contributed  to 
the  fact  that  the  cholera  bacilli,  as  he  supposes,  were  enabled  to 
remain  longer  in  the  water,  were  carried  into  the  aqueduct,  in 
some  parts  of  which,  as  the  house  reservoirs  where  the  water  not 
being  in  motion  leaves  a  precipitate  and  has  a  warm  temperature, 
they  again  became  virulent  and  even  began  to  multiply.  It  is 
hardly  necessary  to  dilate  on  the  fact  that  this  supposition,  how- 
ever great  its  probability,  lacks  verification  by  facts. f 

*  Hueppe,  Die  Cholera-Epidemie  in  Hamburg.  1892.  Berliner  Kli- 
nisclie  Wochenschrift,  1893,  Nos.  4-7. 

t  Later  addition  :  The  spreading  of  cholei-a,  principally  through 
water,  is  very  strongly  substantiated  by  the  last  investigations  of  Prof. 


—  361  — 

The  .seed  of  cholera,  the  cholera  bacterium  (the  so-called 
"  comma  bacillus  "  ),  was  discovered  by  Koch.  He  did  not  pay 
due  attention  to  the  conditions  of  the  surrounding  nature,  whether 
local  or  temporary.  He  and  his  followers  are  justly  reproached 
also  for  this,  that  the  term  "  contagiousness  "  was  employed  by 
them  in  the  sense  in  which  the  term  "  infectiousness  "  is  ordi- 
narily used,  and  thus  cholera,  in  spite  of  other  investigations 
(among  which  I  may  class  also  my  own,  in  accord  with  which 
cholera  is  but  slightly  contagious,  i.  e.  it  is  but  very  seldom  trans- 
mitted directly  from  one  person  to  another),  was  considered  as 
a  directly  contagious  disease ;  it  is  attributed  to  them  that  this 
fact  has  engendered  a  sort  of  panicky  feeling  toward  cholera, 
and  that  it  assisted  in  the  adoption  of  but  very  one-sided  meas- 
ures for  its  prevention.  According  to  Hueppe,  the  observa- 
tions made  during  the  recent  epidemic  of  cholera  at  Hamburo- 
have  succeeded  in  completely  eradicating  the  teaching  of  the 
contagiousness  of  cholera.  This  has  also  been  verified  by  the 
observations  of  Dr.  Wermel  during  the  recent  epidemic  in  Nij- 
ni  Novgorod  (vide  "  Meditzina,"  1892,  Nos.  36  to  37). 

According  to  Hueppe,  the  cholera  bacilli  are  destroyed  en 
masse  in  the  large  intestine  (by  the  acidity  of  its  contents,  as 
he  assumes),  while  those  which  remain  and  escape  from  the  af- 
fected organism  alive,  do  not  possess  any  virulency,  any  power 
to  infect,  on  account,  as  Hueffe  thinks,  of  the  deficiency  of 
oxygen  in  the  biological  processes  of  the  small  intestine  (a  con- 
dition approaching  that  of  anserobiosis).  The  cholera  bacteria 
become  again  virulent  and  multiply  outside  of  the  affected  or- 
ganism under  conditions  of  which  we  know  nothing.  The  ob- 
servations, made  during  the  former,  as  well  as  during  the  recent 
epidemic,  to  the  effect  that  cholera  is  but  slightly  contagious 
and  is  but  rarely  transmitted  directly  from  a  sick  person  to  a 
healthy  one,  speak  certainly  in  favor  of  Hueppe's  assertion, 
thus  constituting  his  chief  bulwark.  But  the  case  brought  for- 
ward by  Hueppe  in  proof  of  the   slight  contagiousness  of  the 

Koch.  R.  Koch,  Ueber  die  Cholera  iu  Deutschland  wahrend  des  Winters 
1892  bis  1893  (in  the  Deutsche  Medic.  AVochenschrift,  IS^o.  36, 1893) ;  also  R. 
Koch,  Cholera  und  Wasserfiltration  (in  Berliner  Klinische  Wochenschrift, 
Xo.  27,  1893). 


—  362  — 

cholera  bacilli  expelled  from  the  yick  organism  (in  this  case  u 
child  devoured  the  excreta  of  his  father  affected  by  cholera,  as 
they  resembled  rice  soup,  and  remained  unaffected),  can  hardly 
prove  anything,  because  of  its  singularity  ;  it  is  possible  that  the 
child  possessed  an  individual  non-predisposition  to  cholera,  a 
natural  immunity  toward  it.  I  may  as  well  state  here  that 
the  various  experiments  of  swallowing  pure  cultures  of  cholera 
bacteria,  as  has  l)een  done  by  Pettenkofer.  Emmerich  and  some 
A'ienna  physicians,  without  any  bad  results  occurrmg  therefi'om. 
can  also  hardly  be  considered  as  proving  anything :  not  to  speak 
of  the  individual  immunity  (although  it  would  be  straining  the 
point  to  constantly  consider  the  same),  we  are  hardly  justified  in 
judging  by  the  degree  of  virulence  of  the  cholera  bacilli  devel- 
oped under  artificial  conditions  of  pure  cultures,  of  the  virulency 
of  the  cholera  bacteria  which  left  the  affected  organism  and  un- 
derwent a  development  among  unknown,  to  us.  conditions  of 
the  surrounding  nature. 

The  rare  cases  in  which  there  was  a  direct  transmission  of 
cholera  from  tbe  sick  to  the  healthy,  Hueppe  explains  by  the 
fact  that  in  the  presence  of  a  severe  diarrhoea  the  bacteria  are 
enabled  to  rapidly  traverse  the  intestines,  and  therefore,  as  he 
thinks,  remaining  but  for  a  short  time  in  a  medium  deficient  in 
oxygen,  they  emerge  from  the  affected  organism  with  a  suffi- 
ciently preserved  degree  of  virulence.  The  comparatively  fre- 
quent occurrence  of  cholera  to  be  seen  among  the  washer- 
women who  handle  linen  not  sufiiciently  disinfected,  Hueppe 
considers  as  due  partly  to  the  presence  in  the  Imen  of  enormous 
numbers  of  bacteria  of  cholera,  as  well  as  of  cholera  toxine. 
and  also  to  the  fact  that  the  choleraic  bacteria,  remaining  in  the 
linen  mixed  with  the  excreta,  that  is,  living  outside  of  the  or- 
ganism, may  become  anew  sulficiently  virulent. 

The  universally  adopted  theory  of  the  contagiousness  of  chol- 
era, as  based  on  the  above-discussed  facts  and  considerations, 
is  as  follows :  the  cholera  bacteria  enter  the  org-anism  together 
with  the  food  and  drink,  per  os,  multiply  exceedingly  in  the 
small  intestines,  invading  also  their  walls,  produce  a  toxine,  cause 
an  extremely  acute  and  severe  affection  of  the  stomach  and  in- 
testines, as  evidenced  by  nausea  and  diarrhcea,  and  then,  on  ac- 


—  363  — 

count  of  the  great  and  rapid  loss  of  the  fluid  portions  of  the 
organism  and  especially  on  account  of  the  absorption  of  the 
above-named  toxine,  they  call  out  the  phenomena  of  the  algid 
stage  of  cholera,  so  peculiar  to  the  disease,  and  of  which  we 
shall  speak  later. 

The  Form  and  Course  of  the  Disease. 

In  accord  with  the  plan  of  my  lecture,  I  shall  not  touch  on 
the  epidemiology  of  cholera.  I  will  only  say,  that  during  the 
cholera  epidemics  there  are  observed,  more  frequently  than  at 
other  times,  intestmal  catarrhs  (diarrhoese),  nervous  disturbances 
of  a  neurasthenic  character,  thanks,  of  course,  to  the  panicky 
feeling  towards  cholera  prevalent  in  the  population,  and  also 
gastric  disturbances  of  a  dyspeptic  nature,  partly  also  of  nervous 
origin,  partly  as  a  result  of  the  sudden  change  in  dietetic  habits, 
of  the  monotonous  food,  of  the  constant  use  of  boiled  water,  and 
also  as  a  result  of  the  employment  of  various  "  preventive"  drops, 
as  hydrochloric  acid  and  others. 

I  will  now  take  up  the  various  choleraic  affections,  but  I 
will  call  your  attention  only  to  their  most  important  characteris- 
tics, the  symptoms  and  the  course,  by  which  we  must  be  guided 
in  making  a  diagnosis  and  in  prescribmg  treatment. 

The  incubation  period,  occupied  by  the  time  when  the  infec- 
tion took  place  until  the  appearance  of  the  disease,  is  short,  usu- 
ally between  one  and  three  days. 

We  distinguish  three  varieties  of  choleraic  affections. 

Choleraic  diarrlioea.  —  AVith  a  condition  of  general  malaise 
the  patient  has  abundant  fluid  stools  but  slightly  colored  with 
bile,  usually  of  a  painless  nature,  but  accompanied  by  consider- 
able abdominal  gurgling.  The  disease  either  passes  away  in  a 
few  days  (with  or  even  without  treatment),  or  passes-  into 
cholerine,  or  directly  into  cholera.  The  character  of  the  sudden- 
ly appearing  diarrhcea,  during  an  epidemic  of  cholera,  as  to 
whether  it  be  of  a  choleraic  nature  or  not,  can  with  certainty  be 
decided  only  by  a  bacteriological  examination  of  the  excreta ; 
without  this  last  a  probable  diagnosis  only  is  possible,  but  not 
a  positive  one.     But  the  bacteriological  examination,  so  impor- 


—  364  — 

tant  f(n-  defining  the  general  cliaracter  of  an  epidemic  affection, 
is  not  practicable  for  the  purpose  of  diagnosticating  cholera  in 
private  practice  during  an  epidemic :  the  results  of  such  an  ex- 
amination are  not  obtained  soon  enough,  but  at  a  comparatively 
late  time,  so  that  is  impossilile.  while  waiting  for  them,  to  leave 
the  sick  person  witliout  any  treatment  at  a  time  when  every 
hour  is  precious,  and  if  he  happens  to  suffer  from  cholerine  or 
cholera,  then  every  moment  is  invaluable.  Besides,  it  is  unrea- 
sonal)le  to  waste  time  and  energy  on  a  minute  bacteriological 
examination  during  a  cholera  epidemic,  when  the  physician's 
time  is  usually  wholly  occupied  and  his  energy  is  in  a  state  of 
extreme  tension.  Consequently  in  cases  of  diarrhoea  of  which 
we  speak  now.  we  must  be  content  with  a  prol^able  diagnosis. 
As  what  concerns  treatment  in  such  cases,  it  will  l)e  spoken  of 
later. 

Chohrrine.  —  (leneral  malaise,  a  slight  felaile  condition,  vom- 
iting and  diarrhcea  of  abundant  liquid  discharges,  at  first  col- 
ored, even  though  slightly,  by  bile,  later  colorless;  great  thirst, 
ver}-  little  urine,  pulse  weak,  a  rapid  decrease  in  the  bodj^  fat, 
cramps  in  the  calves,  general  weakness,  and  weakness  of  the 
voice.  In  a  few  days  the  disease  passes  away,  the  patient  is 
convalescent,  l)ut  for  a  long  time,  for  weeks  together,  he  re- 
mains very  weak.  In  other  less  fre([uent  cases,  with  a  lack  of 
pro]3er  treatment  and  nursing,  the  morbid  phenomena  mcrease 
and  there  appear  syiiiptoms  of  the  algid  stage  of  genuine  cholera, 
during  \Ahich.  or  during  that  of  reaction  following  the  algid 
stage,  the  patient  succumbs;  but  with  assistance  at  the  proper 
time  even  such  cases  may  tend  to  terminate  favoral)ly. 

(jri'tiuinr  cliolera  develops  either  fro]n  the  above-outlined  ail- 
ments or  more  frequentlv  directly :  after  one  or  more  days  of 
slight  and  pauiless  diarrh(pa  ('•  the  prodromal  "),  there  sudden- 
ly takes  place  an  attarlx  of  cliolera  :  the  evacuations  l)ecome  all 
at  once  frequent  and  abundant,  tliey  lose  their  yellow  coloring 
and  take  on  a  resemblance  to  rice-soup  ;  to  this  there  is  soon 
superadded  vomiting,  which  consists  in  the  beguuiing  of  the 
gastric  contents,  then  of  biliary  matter,  and  finally  of  similar 
rice-soup-like  liquid  masses.  Even  a  few  hours  of  such  a  con- 
dition may  Ije  followed  by  the  phenomena  of  the  so-called  cold 


—  365    — 

period  of  cholera  (stadi  urn  algidniii,  s.  cyanoticuin,  s.  asplncti- 
cuni )  :  the  patient  lies  in  a  condition  of  extreme  weakness, 
speechless,  at  times  moaning  and  whining  with  a  weak  voice 
from  the  pain  caused  by  the  nuiscular  cramps,  which  however 
pass  rapidly;  when  asked  anything  he  replies  slowly  (conscious- 
ness weak)  and  in  an  exceedingly  weak  voice  ;  the  l)ody  is  cold 
to  the  touch,  the  bodily  fullness  (turgor  vitalis )  is  sharply  dim- 
inished, the  cheeks  fallen  in,  the  nose  sharp,  the  eyes  deep  in 
their  sockets,  the  skin  is  cyanotic  and  ^v■l■inkled,  and  if  caught 
between  the  fingers  does  not  return  to  its  previous  condition ; 
there  is  an  insatiable  thirst,  no  urine,  pulse  hardly  perceptil)le, 
tones  of  the  heart  extremeh'  weak.  With  the  appearance  of 
the  algid  stage  the  vomiting  and  diarrh(ea  usually  diminish. 

The  phenomena  of  the  algid  stage  are  undoubtedl}',  but  onl}^ 
to  some  extent,  determined  by  the  great  loss  of  tlie  fluid  por- 
tions of  the  organism,  and  by  the  results  of  this  loss,  as  thicken- 
ing of  the  blood,  disturbances  of  the  circulation,  deficiency  of 
oxygen  in  the  blood  and  tissues,  etc.,  caused  by  such  a  great 
traUsudation  into  the  intestines  :  the  loss  of  the  fluid  parts  of 
the  organism  and  the  results  dependent  thereon  are  insufficient 
to  explain  the  above-named  phenomena.  There  occur  cases, 
and  very  severe  ones  at  that,  which  present  an  extreme  devel- 
opment of  the  algid  stage,  the  patients  dymg  during  it,  while 
they  have  neither  diarrhoea  nor  vomiting  (cholera  sicca)  and 
autopsy  reveals  but  a  trifling  exudation  into  the  intestines. 

Moreover,  every  physician  who  has  ever  seen  a  goodly  num- 
ber of  cholera  patients,  is  well  aware  of  the  fact  that  very  often 
there  is  to  be  observed  a  disproportion  between  the  quantity  of 
the  liquid  evacuations  and  the  symptoms  of  the  algid  stage : 
the  first  may  be  very  considerable,  while  the  latter  are  insignifi- 
cant, and  contrariwise.  It  is  thus  evident  that  outside  of  the 
great  loss  of  the  fluid  parts  of  the  organism  there  must  also  be 
some  other  cause  to  account  for  the  algid  stage  of  the  disease. 
As  such  was  considered  the  toxine  produced  by  the  cholera 
bacteria.  As  a  matter  of  fact  both  Xicati  and  liietsch  obtained 
from  pure  cultures  of  bacteria  a  poisonous  body,  the  introduc- 
tion of  which  into  the  systems  of  animals  caused  a  fall  in  the 
temperature,  paralytic  phenomena  and  finally  death.      Out  of  the 


—  366  — 

contents  of  the  small  intestines,  as  found  on  autopsies,  Hueppe 
obtained  a  toxine  which  he  considers  to  be  a  peptone  produced 
from  the  albuminoid  constituents  of  the  intestinal  contents  un- 
der the  influence  of  the  cholera  bacteria  and  of  deficiency  in 
oxygen.  He  also  obtained  an  identical  toxine  from  the  contents 
of  the  large  intestuie  and  from  the  intestmal  secretions  of  chol- 
era patients,  but  in  a  much  smaller  quantity ;  this  leads  him  to 
think  that  the  above  referred  to  toxine  is  partly  absorbed  by 
the  small  intestine,  and  is  partly  destroyed  by  the  acidity  of  the 
large  intestine.  Introduced  into  the  systems  of  animals,  as 
guinea-pigs,  rabbits  and  dogs,  the  cholera  toxine  produced  a 
fall  of  the  temperature,  paralytic  symptoms,  and  finally  death  : 
the  paralytic  phenomena  were  sometimes  preceded  by  severe 
dyspnoea  and  cyanosis ;  the  autopsy  of  the  animals  so  killed 
revealed  the  fact  that  the  kidneys,  liver,  and  the  heart  have  un- 
dergone, according  to  Hueppe,  changes  similar  to  those  found 
in  the  same  organs  of  patients  who  died  during  the  algid  period 
of  cholera,  and  on  whom  autopsies  were  performed.  The  ab- 
sorption of  the  cholera  toxine  is  certainly  very  probable,  and 
may  be  considered  as  a  generally  accepted  fact,  otherwise  it 
would  be  difficult  to  explain  the  so  promment  and  apparently 
toxic  symptoms  of  the  algid  stage.  (Hueppe  assumes  that  he 
succeeded  in  proving  the  presence  of  this  toxine  in  the  first 
urine  excreted  during  the  reaction  stage  of  cholera,  which  fol- 
lows the  anuria  of  the  algid  stage.)  It  is  beyond  doubt  that  it  is 
not  so  much  the  loss  of  the  liquid  portion  of  the  organism  as  the 
choleraic  toxine,  which  determmes  the  acute  affection  of  the 
nervous  system  in  general  and  that  of  the  vaso-motor  in  par- 
ticular, as  observed  during  the  algid  stage,  as  well  as  the  changes 
of  the  protoplasm,  such  as  the  cloudiness  and  the  coagulation-ne- 
crosis of  the  muscular  heart  fibres,  of  the  hepatic  and  renal 
epithelia,  which  are  all  found  at  the  autopsies  of  persons  dymg 
durmg  this  stage  of  the  disease.  The  affection  of  the  last  (the 
epithelium  of  the  kidney)  causes  a  nepliritis,  the  symptoms  of 
which  become  prominent  during  the  next  reaction  stage,  on  the 
pathological  anatomy  of  which  I  may  as  well  touch  now : 
the  vessels  and  the  interstitial  substance  of  the  renal  parenchyma 
are  not  affected,   but  the    morbid   pi'ocess    (coagulation-neero- 


—  367  — 

sis)  attacks  the  epithelium  of  the  glomeruli  and  of  the  convo- 
luted tubules,  and  it  (the  epithelium)  becomes  detached ;  in 
cases  of  recovery,  the  epithelium  is  rapidly  regenerated  and  the 
nephritis  does  not  pass  into  a  chronic  condition  (Ley den,  Berl. 
Klinische  Woclienschrift,  1893).  Without  stopping  to  con- 
sider, in  accord  with  the  plan  of  my  lecture,  all  the  anatomo- 
pathological  data  peculiar  to  the  algid  stage  of  cholera  and 
known  to  you  from  the  systematic  course  of  internal  pathology, 
as  the  thickening  of  the  blood,  the  drying  up  of  the  tissues  and 
the  like,  1  will  only  call  your  attention  to  the  changes  in  the 
spleen  so  characteristic  in  cholera  (Prof.  Stiller,  in  the  i^erlin. 
Klin.  Wochenschrift,  1898) ;  this  last  is  found  in  patients  dy- 
ing during  the  algid  stage  as  diminished  in  size  and  wrinkled, 
a  condition  analogous  to  that  of  the  vessels  and  depending, 
quite  probably,  on  identical  causes.  According  to  certain  m- 
vestigations,  the  spleen  in  the  prodromal  period  of  cholera  is 
hypertrophied,  just  as  it  is  in  other  infectious  diseases.  Durhig 
the  stage  of  reaction  the  spleen  again  increases  in  size. 

Patients  die  frequent!}^  while  in  the  algid  stage,  especially 
during  the  very  height  of  the  epidemic.  If  they  recover,  then 
the  clearly  and  unmistakabl}'  pronounced  algid  stage  is  never 
followed  by  an  immediate  recovery,  but  there  take  place  new 
and  very  variable  morbid  phenomena,  which  are  collectively 
designated  under  the  name  of  reaction  period  or  under  that 
of  choleraic  typhoid  ;  although  the  incorrectness  of  this  last  term 
is  admitted  by  everybody,  still  it  became  so  popular  that  it  is 
employed  by  all.     These  phenomena  are  of  three  varieties : 

1.  Most  frequentl}^  there  is  an  acute  nephritis  (as  evidenced 
by  a  small  quantity  of  urine  containing  much  albumen,  numbers 
of  cylinders  and  epithelial  cells),  accompanied  by  severe  ursemic 
symptoms. 

2.  Much  less  frequent  is  a  febrile  condition,  accompanied  by 
typhoid  symptoms,  without  any  renal  affection,  due  evidently 
to  the  considerable  alterations  produced  during  the  preceding 
stages  in  other  organs,  —  in  the  intestines,  liver,  heart,  spleen, 
blood,  etc. 

8.  Various  morbid  conditions,  their  origin  apparently  due  to 
other  infections  which  found  such  a  favorable  soil  in  an  organ- 


—  368  — 

ism  attacked  by  cholera :  diphtheria  of  the  intestines,  of  the 
urinary  and  biliary  bladders,  of  the  vagina,  and  also  of  the 
pharnyx  (in  conjunction  with  parotitis),  of  the  larnyx  with 
bronchitis,  and,  even  if  not  frequently,  with  pneumonia  and  in- 
flammation of  the  serous  membranes,  various  affections  of  the 
skin  (as  eruptions),  ulcers,  abscesses,  erysipelas. 

All  the  three  varieties  of  the  morbid  processes  occurring  dur- 
ing the  reaction  period  may  occur  simultaneously  in  the  most 
variable  combinations. 

A  fatal  issue  is  of  frequent  occurrence  also  during  this  period. 
Recovery  after  a  severe  pronounced  attack  of  cholera  is  a  slow 
process. 

Preventr^e  Measuees. 

Following  the  plan  laid  out  for  my  lecture,  I  cannot  stop  to 
thoroughly  discuss  this  most  important  subject,  but  will  only 
make  a  few  observations. 

Quarantines,  as  employed  heretofore,  proved  to  be  inefficient; 
but  it  does  not  occur  to  me,  that  the  question  about  quarantines 
has  been  decided  and  that  they  had  been  recognized  as  ineffi- 
cient or  even  impossible.  To  be  sure  it  is  difficult  to  picture  to 
one's  self  the  establishment  of  an  efficient  and  very  strict  quar- 
antme  along  all  the  boundaries  of  the  European  governments, 
which  are  thickly  populated  and  keep  up  such  a  lively  commu- 
nication among  themselves  :  this  would  cause  great  embarrass- 
ment and  could  only  be  obtained  at  the  cost  of  considerable 
expenditures.  But  the  quarantine  along  the  highways  leading 
from  the  birthplace  of  cholera,  from  Asia,  is  a  different  matter. 
Our  present  Central  Asiatic  boundaries,  tlirough  which  the  re- 
cent epdiemic  of  cholera  forced  its  way,  extend  mostly  through 
wilderness,  and  do  not  present  any  possible  means  for  the  estab- 
lishment of  a  strict  quarantine ;  but  it  is  pointed  out,  that  not 
far  from  these  boundaries  there  are  located  mountain-chains 
which  admit  of  a  passage  only  through  certain  places,  where  it 
would  be  a  very  easy  matter  to  establish  the  strictest  quaran- 
tine which  would  embarrass  only  the  hisignificant  caravan 
trains.  We  certainly  are  not  to  conclude  from  the  fact  that  it 
is  impossible  to  establish  reliable  quarantines  over  all  tlie  Asiatic 


—  369  — 

liighvA'ays,  that  it  is  useless  to  do  so  wherever  it  is  possible.  A 
more  direct  application  of  the  quarantine  over  the  most  impor- 
tant road  from  India,  the  Suez  Canal,  would  probably  bear  bet- 
ter results,  if  not  for  the  selfish  opposition  of  England,  which 
makes  it  impossible  of  realization.  The  brevity  of  the  incuba- 
tion period  of  cholera  does  not  require  any  very  prolonged  quar- 
antining. It  is  hardly  probable,  that  cholera  is  transferred 
through  goods,  unless  it  be  certain  special  ones,  as  old  clothes 
and  others,  the  admission  of  which  is  usually  forbidden  by 
self-protecting  governments.  Special  attention  must  be  paid  to 
the  dirty  linen  of  the  passengers,  by  submittmg  it  to  strict  dis- 
infection or  even  destroying  it  by  fire.  It  is  true,  that  notwith- 
standing all  the  quarantine  measures,  if  the  quarantine  is  kept 
but  for  a  limited  time,  which  would  otherwise  cause  extreme 
embarrassment  in  places  with  such  an  extensive  travel  as  for 
instance  the  Suez  Canal,  *  there  may  remain  unobserved 
and  may  pass  on  persons  sick  with  but  a  slight  choleraic  affec- 
tion, choleraic  diarrhea,  but  who  may  however  carry  with  them 
the  seed  of  infection  and  under  favorable  circumstances  become 
the  cause  of  an  epidemic.  Furthermore,  from  observations 
made  in  Hamburg,  it  is  made  certain,  that  in  persons  who  re- 
covered from  cholera,  there  are  to  be  found  for  a  long  time,  even 
after  the  intestinal  secretions  have  entirely  taken  on  their  normal 
form,  in  these  secretions  the  characteristic  comma  bacilli.  How- 
ever, the  fact  that  the  quarantine  measures  do  not  act  as  an 
absolute  bar  to  the  invasion  of  cholera,  need  not  mean  that  we 
must  neglect  their  undoubted  usefulness  to  diminish  to  a  very 
great  extent  the  possibility  of  its  being  transferred. 

To  thoroughly  interrogate  every  single  passenger,  as  was 
practised  during  the  recent  epidemic  on  the  railroad  lines,  is  of 
course  a  superfluous  procedure ;  but  the  watching  over  the 
travelling  public,  at  least  along  tracts  with  a  considerable  travel, 
on  railroad  and  on  river  lines,  the  separation  of  the  evidently 

*  (A  later  addition.)  The  last  (1894)  international  sauitary  conference 
concluded  that  in  place  of  the  quarantine  at  the  Suez,  the  sanitary  in- 
spection of  the  sailing  vessels  by  physicians  be  enforced  more  strictly,  if 
they  arrive  from  unreliable  and  doubtful  ports,  at  the  time  they  leave 
them,  as  well  as  during  their  journey. 


—  370  — 

affected  ones  from  the  healthy,  the  application  of  disinfection 
and  the  rendering  of  necessary  aid,  are  of  course  necessary 
measures. 

I  will  not  stop  here  to  discuss  the  subject  of  disinfection,  its 
means  and  ways,  its  application  to  the  patient,  to  his  linen  and 
his  residence,  to  the  affected  locality  and  houses,  to  the  tramway 
cars,  steamboats,  etc.,  as  all  this  is  discussed  for  your  benefit  by 
a  competent  person  in  special  lectures. 

Nor  will  I  speak  here  of  the  measures  touching  upon  the  re- 
establishment  of  the  normal  conditions  in  the  affected  localities  ; 
this  is  certainly  desirable,  but  it  must  not  be  done  in  a 
hurry,  as  is  usually  done  during  the  approach  or  even  during 
the  attack  of  the  epidemic,  but  in  a  substantial  manner,  requir- 
ing a  long  time  for  its  completion  in  accord  with  a  matured, 
thought-out  plan. 

I  cannot  help  stating  here,  that  at  the  sight  of  the  above- 
named  hunying  measures  adopted  for  the  re-establishment  of 
former  conditions  of  health,  the  use  of  which  measures  is  doubt- 
ful while  their  cost  is  great,  seeing  the  frequently  unreasonable 
and  unnecessary  expenditure  of  means  for  disinfection,  which 
also  entails  considerable  expenses,  the  thought  occurs  that  it 
were  bettei'  to  devote  the  financial  outlays  thus  expended  to 
obtaining  for  the  indigent  population  of  healthy  food  and  drink, 
as  the  benefit  derived  from  these  dviring  a  cholera  epidemic  is 
of  inestimable  value. 

It  is  absolutely  necessary,  that  a  most  thorough  disinfection 
be  effected  around  the  patient,  not  only  in  cases  of  a  clearly  pro- 
nounced choleraic  ailment,  but  in  the  presence  of  every  doubt- 
ful diarrhoea ;  that  the  patient's  excreta,  his  linen  (if  it  be  but 
slightly  soiled,  otherwise  burn  it)  and  objects  surrounding  him 
should  be  disinfected. 

An  important  preventive  measure  is  the  careful  supervision 
over  persons  arriving  in  the  given  locality,  the  isolation  of 
those  who  present  signs  of  an  apparently  choleraic  and  even  of 
a  doubtful  affection,  the  innnediate  application  of  thorough  dis- 
infection and  also  the  immediate  rendering  of  the  necessary 
assistance,  l^jvery  case  to  which  we  succeed  in  applying  thor- 
oughly lljese  measures,  diminishes  the  possibility  of  developing 


—  371  — 

or  of  increasing  the  epidemic.  The  fortunate  condition  of  things 
in  Moscow  during  the  last  epidemic  is  undoubtedly  to  be  as- 
cribed m  a  great  measure  to  the  careful  and  skillful  application  of 
the  enumerated  measures. 

In  July  of  last  yea,r,  in  view  of  the  serious  application  of  the 
above-named  and  other  measures,  and  also  on  account  of  other 
considerations.  I  expressed  a  hope  (vide  the  Moscow  Gazette, 
July  16,  1892)  that  the  further  course  of  the  epidemic  would 
be  of  moderate  severity,  at  least  in  the  northern  and  the  north- 
western provinces  of  Russia,  heretofore  not  visited  by  the  disease. 
The  course  of  the  epidemic  in  Nijni  Novgorod,  Moscow  and  St. 
Petersburg  and  in  other  localities  of  the  above-named  provinces 
in  Russia  has  completely  justified  my  expectations  ;  while  on 
the  southwest  the  epidemic  was  severe.  I  have  no  doubt,  but 
that  if  in  Baku  and  other  places  of  Transcaucasia,  in  Astrachan, 
Tzarytzin.  Saratov  and  Samara,  the  same  measures  had  been 
adopted  as  were  practised  in  Moscow,  instead  of  the  absence, 
not  only  at  the  beginning  but  also  later  on,  of  any  preventive 
measures,  and  instead  of  the  street  riots  which  assisted  so  much 
in  spreading  the  cholera,  the  course  of  the  epidemic  would 
have  been  different ;  it  would  not  have  developed  to  such  a 
degree  in  the  cities  and  would  have  been  prevented  from  in- 
vading the  villages  and  country  places,  where  preventive  as 
well  as  any  curative  measures  are  so  difficult  of  application, 
while  the  population,  which  is  generally  poorly  fed,  was  ex- 
hausted by  a  previous  failure  of  the  crops. 

The  individual  measiires  of  pre  caution  can  be  summed  up  in 
this,  that  one  must  not  in  any  way  alter  his  habitual  mode  of 
living,  by  which  we  mean  a  mode  which  preserves  one's 
health  in  good  order ;  in  case  there  be  any  disturbance  of  health 
one  must  at  once  look  for  a  physician's  advice,  also  on  the  return 
of  the  habitual  disturbances,  and  especially  those  of  the  diges- 
tive organs  ;  he  must  follow  a  certain  once  prearranged  plan  of 
treatment  and  hygiene,  but  under  no  circumstances  is  he  to  be 
allowed  to  treat  himself  by  various  "  cholera"  measures,  drops, 
etc.,  so  extensively  advertised  during  the  prevalence  of  an  epi- 
demic ;  when  perfectly  healthy  he  must  avoid  the  use  of  the  so- 
called  (psuedo)  preventive    measures,    as  for  instance  hydro- 


—  372  — 

chloric  acid,  quinine,  etc.,  wbicli  will  only  tend  to  disturb 
digestion,  thus  creating  a  predisposition  to  choleraic  affections. 
Pure  spring  water  need  not  necessaril}-^  be  boiled  for  drinking 
purposes,  while  water  of  doubtful  purity,  if  its  use  cannot  be 
avoided,  must  previously  be  allowed  to  settle  down,  be  strained 
and  boiled,  and,  I  must  say,  it  should  be  drunk  only  when  re- 
cently boiled,  wliile  water  which  had  been  boiled  a  long  time 
previously  should  not  be  used  for  drinking  purposes. 

The  Teeatment. 

I  alluded  m  the  beginning  of  the  lecture  to  the  fact,  that, 
to  replace  as  far  as  it  is  in  my  power  (because  of  the  absence 
of  cholera  patients)  the  lack  of  clinical  individualization, 
I  wdll  discuss  at  least  the  most  important  situations  in  which  a 
cholera  patient  may  find  himself,  and  to  which  treatment  must 
be  applied :  I  must  also  add  that  this  is  the  more  necessary, 
because  of  the  rapid  course  of  the  disease,  and  the  lack  of  time 
at  the  physician's  disposal,  for  the  number  of  sick  is  usually 
great ;  a  calm  and  circumstantial  analysis  of  the  patient's 
condition  is  much  more  difficult  in  cholera,  than  in  any  other 
disease,  and  it  is  therefore  necessary  to  have  become  previously 
acquainted  with  the  peculiarities  of  treatment  of  the  various 
conditions  in  which  the  patient  may  be  found.  I  must  how- 
ever take  a  preliminary  review  of  some  of  the  general  therapeu- 
tic statements  in  connection  with  the  treatment  of  cholera.  1 
consider  it  as  of  special  utility  for  yon  as  beginners  :  a  correct 
view  and  a  clear  intelligence  constitute  the  most  important  re- 
quisites of  successful  activity. 

We  are  frequently  told,  to  be  sure  not  by  medical  men,  that, 
as  the  statistical  data  prove  the  mortality  from  cholera  to  be 
the  same  under  all  systems  of  treatment,  which  goes  to  show 
the  impotence  of  every  kind  of  treatment  of  cholera,  it  is  use- 
less to  waste  any  means  on  it,  and  it  were  better  to  devote  the 
means  on  hand  to  obtaining  nourishmg  food  to  that  portion  of 
the  population,  vhich  h  particularly  liable  to  fall  a  prey  to  the 
disease  on  account  of  insufficient  nourishment.  This  assertion 
can    l)e    refuted    in    a    few    words :     only    a    layman,    who    in 


—  373  — 

judging  of  the  effectiveness  of  treatment  relies  on  such  doubt- 
ful data  as  those  lent  by  statistics,  could  pronounce  himself 
against  the  treatment  of  cholera  :  but  every  physician  who  had 
the  opportunity  of  seeing  a  sufficient  numl)er  of  cholera  patients. 
and  who  perceived  clearly  the  difference  in  the  course  and  the 
issue  of  the  disease  between  the  cases  in  which  treatment  was 
begun  early,  and  those  that  were  treated  late,  cannot  but  be 
fully  persuaded  of  the  effectiveness  of  and  the  crying  urgency 
for  treatment  of  cholera  patients. 

It  is  with  a  certam  degree  of  pomposit}-  that  the  assertion  is 
made  that  it  is  not  the  cholera,  but  the  cholera  patient  who  must 
be  treated.  You  who  are  well  informed  of  the  fundamental 
principle  of  clinical,  i.  e.  practical  activity,  namely,  that  in  all 
diseases,  without  any  exceptions,  we  treat  the  patient  and  not  the 
disease,  will  be  astonished  and  taken  aback  by  such  an  asser- 
tion, and  you  will  naturally  ask:  how  otherwise?  and  when 
can  we  see  and  treat  the  disease,  if  not  in  the  patient  ? 

As  you  know,  there  exists  no  specific  remedy  for  cholera,  i.  e. 
such  a  remedy  as  would  not  act  upon  some  one  separate  symp- 
tom of  this  disease,  but  striking,  so  to  say,  the  very  centre  of 
the  affection,  would  thus  act  on  all  the  symptoms,  and  by  de- 
stroying them,  would  bring  about  a  cessation  of  the  disease, 
as  quinme  does  in  malaria,  sodium  salj'cilate  in  acute  articular 
rheumatism,  and  to  a  lesser  extent,  as  the  results  of  the  treat- 
ment are  not  so  positive,  mercury  and  the  iodides  in  syphilis.  As 
we  have  no  such  remedy,  it  remains  for  us  here,  as  m  other  dis- 
eases for  which  there  exist  no  specific  remedies,  to  pursue  a 
symptomatic  treatment,  combating  separately  the  symptoms 
which  exhaust  the  patient,  and  subject  his  life  to  danger,  and 
thus  we  enable  the  patient  to  tide  over  the  disease,  and  save 
his  life. 

Still  it  is  strange  to  hear  dou1)ts  expressed  regarding  the  pos- 
sibility of  a  specific  treatment  of  cholera.  Where  can  there  be 
a  basis  for  such  doubts  in  view  of  the  above-named  existing  spe- 
cific remedies  for  certain  diseases  ?  And  especially  at  the  pres- 
ent time,  when  there  had  been  opened  to  therapy  so  many  new 
and  promising  ways  creating  a  possibility  of  treating  the 
most  serious  diseases  by  the  aid  of  the  secretions  and  of   the 


—  374  — 

tissues  of  the  organism  itself,  uiid  also  by  the  products  of 
the  life-activity  of  the  j)athogenic  microbes,  the  greatest  ene- 
mies of  the  organism.  Who  is  able  to  foretell  the  various  means, 
the  remedies,  the  combinations  of  various  means  and  remedies, 
that  the  therapy  of  the  future  will  make  use  of  ? 

.  Stranger  still  appears  such  an  assertion  :  "  For  other  (out- 
side of  cholera)  infectious  diseases,  as  typhoid,  pneumonia,  etc., 
we  have  long  ago  rejected  specific  remedies,  having  concluded, 
that  symptomatic  treatment  only  (?)  will  assist  the  organism  in 
getting  rid  of  the  infectious  agency."  But  this  is  not  true  ; 
nobody  ever  rejected  them  ;  let  there  be  found  to-morrow  as  re- 
liable a  remedy  for  typhoid  and  pneumonia,  as  quinine  is  for 
malaria  or  salycilate  of  soda  for  acute  articular  rheumatism,  and 
every  physician,  including  the  author  of  the  above  statement, 
will  at  once  resort  to  it,  reducing  to  a  minimum,  if  not  discharg- 
ing altogether,  the  usual  symptomatic  treatment ;  thus,  for  in- 
stance, it  happened  with  the  symptomatic  treatment  of  acute 
articular  rheumatism,  which  was  being  employed  at  the  time 
before  the  specific  effect  of  sodium  salycilate  became  known. 
It  is  rather  odd  to  hear  it  stated,  that  "  the  symptomatic  treat- 
ment only  will  enable  the  organism  to  free  itself  from  the  infec- 
tion,'' in  view  of  the  effects  of  the  above-named  specific  remedies 
in  malaria  and  acute  articular  rheumatism,  effects  which  excel 
so  much  by  their  accuracy  and  rapidity  the  symptomatic  treat- 
ment of  those  diseases,  for  which  we  have  no  specific  treatment. 

Equally  strange  is  the  identification  of  the  specific  treatment 
with  the  routine  one. 

This  is  a  confounding  of  ideas.  Routine  is  not  a  peculiarity 
of  an}^  metliod  of  treatment,  but  surely  a  deplorable  quality  in 
the  physician  himself:  both  the  specific  and  the  symptomatic 
methods  of  treatment  may  be  applied  in  a  routine  manner,  and 
again  they  may  also  be  employed  in  a  non-routine  way,  so  as  to 
pay  due  attention  to  the  characteristic  peculiarities  of  the  given 
case,  of  the  treated  patient,  which  would  but  mean  to  subject 
him  to  a  system  of  individualization  in  treatment. 


I  will  turn  now  to  the  discussion  of  the  treatment  as  applied 
to  the  various  conditions  in  which  the  patient  may  be  found. 


—  375  — 

1.  The  diarrhcea.  —  It  is  self-understood,  that  not  every  case 
of  diarrhoea  met  with  during  a  cholera  epidemic  is  to  be  treated 
as  a  choleraic  diarrh(Ea.  During  such  a  time  we  may  run  across 
patients  suffering  with  a  chronic  intestinal  catarrh  which 
causes  constipation  intermittent  with  diarrhoea,  or  even  a  continu- 
ous diarrhoea ;  if  the  diarrhoea  from  which  such  patients  suffer, 
remains  during  the  cholera  epidemic  in  the  same  condition  as  it 
was  before,  then  there  is  no  reason  for  changing  the  usual  treat- 
ment of  such  a  diarrhea,  for  attributing  to  it  a  certain  •'  anti- 
choleraic  '"  shade,  thus  inordinatelj^  frightening  the  patient.  I 
will  add  right  here,  that  not  only  in  such  cases,  but  also  in  cases 
of  doubtful  or  even  undisguised  cholera  ailment,  it  is  necessary 
to  insistently  keep  up  the  patient's  spirits  by  encouraging  him 
that  the  disease  he  suffers  from  is  a  "  simple,"  and  not  a  "  gen- 
uine choleraic ''  affection,  thus  averting  as  much  as  it  lies  in  our 
power  the  oppressive  mental  state,  which  is  produced  in  the 
patients  by  the  anxiety  of  falling  a  prey  to  cholera,  and  which 
tends  to  make  their  condition  so  much  worse. 

We  may  also  see  during  the  cholera  epidemic  cases  of  acute 
diarrh(jea,  but  apparently  of  a  non-choleraic  nature,  as  for  in- 
stance, acute  catarrh  of  the  large  mtestine,  as  evidenced  by 
frequent  inclination  to  stool,  tenesmus,  pains,  and  scanty  evac- 
uations with  an  admixture  of  mucus  and  blood. 

However,  such  cases  are  rather  of  infrequent  occurence  dur- 
ing a  cholera  epidemic,  and  the  acute  diarrhcese  met  with  at 
such  times  are  usually,  or  in  all  probability,  of  a  choleraic  nature 
fas  described  above),  or  of  such  a  character,  as  not  having  an 
apparently  Mow-choleraic  nature,  and  they  therefore  give  rise  to 
suspicion  of  their  being  of  a  choleraic  origin  ("  the  doubtful 
cases").  A  positive  diagnosis,  as  we  explained  above,  is  impos- 
sible ;  the  bacteriological  examination,  which  would  positively 
diagnosticate  either  class  of  the  cases,  is  not  applicable  in  prac- 
tice. 

What  then  is  the  treatment  of  such  cases  ?  Having  first 
of  all  informed  yourself  by  a  short  inquiry  of  the  kind  and 
quantity  of  food  and  drink  the  patient  had  been  taking  recently 
and  of  the  character  of  intestinal  evacuations,  and  having  in- 
spected and  palpated  the  abdomen,  you  should  decide    as    to 


whether  or  not  the  intestinal  canal  is  sufficiently  emptied  of 
its  contents.  If  not,  it  must  be  emptied  b}^  the  aid  of  laxatives : 
this  precedure,  so  necessary  in  any  diarrhoea  in  case  of  insuffi- 
cient emptying,  the  more  so  of  overfilling  of  the  intestines,  is 
the  more  necessar}^  in  cholera  affections,  in  which  case  the  lax- 
ative may  he  expected  to  remove  together  with  the  other  in- 
testinal contents  the  cholera  bacteria  which  so  greatly  multi- 
ply in  the  small  intestines,  and  the  toxine  produced  by  them. 

Which  laxative  is  the  most  suitable  for  such  cases  ?  Castor 
oil  or  calomel  with  castor  oil.  I  will  take  up  calomel  ffi^st.  As 
a  laxative  calomel  is  particularly  useful,  as  my  observations 
during  the  former  epidemics  of  cholera,  principally  of  1853  and 
1854,  testify,  in  patients  of  a  robust  or  at  least  not  of  a  weak 
constitution,  with  a  large  abdomen  ;  in  those  who  are  subjected 
to  dyspeptic  gastric  phenomena  (in  such  cases  the  castor  oil  is 
frequently  badly  borne  and  is  vomited  up),  to  habitual  consti- 
pation, jaundice,  to  biliary  colic  attended  with  constant  tender- 
ness on  pressure  over  the  region  of  the  gall-bladder.  I  admin- 
ister a  four  or  live  grain  dose  of  calomel,  repeat  it  in  two  hours, 
and  again  in  two  hours  (if  by  that  time  there  have  not  taken 
place  abundant  evacuations  sufficient  to  empty  the  intestines)  ; 
then  I  give  a  tablespoonful  of  castor  oil,  which  is  usually  better 
borne  after  calomel.  To  patients  who  do  not  present  the 
above-named  peculiarities,  I  only  administer  castor  oil. 

I  will  also  touch  here  on  calomel  as  a  generally  "•  antichole- 
raic"  remedy.  It  was  recommended  as  such  not  only  in  the 
bep-inninor  of  the  disease  when  the  intestines  are  overfilled,  but 
also  for  the  later  stages  attended  by  a  continuous,  even  severe 
diarrhoea,  as  well  as  for  the  algid  stage  of  true  cholera,  under 
the  assumption,  that  if  taken  internally,  it  will  be  converted 
into  corrosive  sublimate,  thus  exerting  a  fatal  effect  on  the 
cholei'a  bacteria  found  in  the  small  intestines.  Galomel  is 
particularly  recommended  for  cholera  by  the  well-known  Mii- 
nich  clinician  Ziemssen.  But  I  will  repeat  here  what  I  said  in 
1885,  concerning  the  use  of  calomel,  namely:  in  cholera  I  did 
not  see  the  slightest  success  from  the  employment  of  calomel 
during  the  two  severe  epidemics  at  Moscow  in  the  years  1853 
and  1854,  when,  in  the  capacity  of  a  resident  pliysician  of  the 


—  377  — 

temporary  cholera  department  in  the  University  clinic,  I  had 
the  opportunity  of  seeing  a  great  many  patients,  and  when  calo- 
mel formed  the  ordinary  treatment  of  the  disease.  Calomel 
was  also  tried  during  the  recent  epidemic  and  it  was  proved, 
that  its  use  was  not  only  of  no  positive,  but  not  even  of  a  doubt- 
ful value.  Besides,  it  is  quite  probable,  that  its  continuous 
employment  results  in  producing  a  harmful  effect  on  the  in- 
testines which  had  already  become  strongly  affected  by  the 
cholera,  and  on  the  kidneys,  the  affection  of  which,  appearing 
during  the  period  of  reaction,  is  of  such  frequent  occurrence  in 
cholera,  and  is  fraught  with  grave  danger  to  an  organism 
severely  shocked  by  the  preceding  course  of  this  disease.  The 
above-named  cases,  in  which,  according  to  my  observations, 
calomel  in  the  begmning  of  the  disease  exerts  an  excellent 
effect  as  a  laxative  remedy,  without,  I  may  add,  the  least  dan- 
ger to  the  patient,  are  the  only  ones,  for  which  I  administer 
the  drug  in  cholera. 

I  will  add  that  for  the  identical  purpose  of  directly  acting  on 
the.  cholera  affection,  by  destroymg  in  the  intestinal  tract  the 
cholera  bacteria  and  the  toxine  or  toxines  produced  by  them, 
there  were  recommended,  besides  calomel,  many  other  drugs, 
notably  salol.  Experience  proved  that  they  were  of  the  same 
value  as  calomel,  as  far  as  their  direct  anticholeraic  effect  is 
concerned,  and  that  they  also  exerted  a  harmful  effect.  Hueppe, 
from  his  observations  during  the  recent  cholera  epidemic,  recom- 
mended specially  tribromphenolbismuth ;  but  data  communicated 
by  him,  as  well  as  the  observations  of  other  physicians,  fail  to 
show  that  this  remedy  deserves  any  greater  credit  than  calomel, 
salol,  and  a  host  of  others  recommended  until  now. 

I  return  now  to  the  treatment  of  the  diarrhoea.  What  is  to 
be  done  for  cases,  in  which,  after  an  evacuation  of  the  intestines 
had  been  effected  b}-  a  laxative,  the  diarrhoea  still  continues,  and 
also  for  those  cases  which  present  no  necessity  for  the  admmis- 
tration  of  a  laxative,  as  the  physician  sees  them  at  a  time  when 
the  intestinal  tract  has  akeady  been  evacuated,  but  meanwhile 
the  diarrhoea  continues,  thus  certainly  debilitating  the  patient? 
In  either  class  of  cases  we  must  first  of  all  give  opium,  namely, 
the  tincture  (tincturaopiisimplexs.thebaica), as  the  most  suitable 


—  378  — 

opium  preparation,  and  as  one,  besides,  which  can  be  divided  in 
doses  most  conveniently,  not  requiring  any  weighing,  like  opium 
purum  and  extr.  opii  aquosuni.  The  employment  of  opium  at 
the  present  time  must  certainly  be  explained. 

During  the  former  cholera  epidemics  opium  may  be  said  to 
have  been  the  most  generally  employed  remedy  in  doubtful  as 
well  as  in  undisguised  cases  of  choleraic  diseases.  At  the  pres- 
ent time  the  matter  is  considered  in  a  different  light:  starting 
with  the  supposition,  that  opium,  by  weakening  the  peristaltic 
efforts  of  the  intestines,  assists  in  the  retention  and  multiplica- 
tion (as  determined  by  the  greater  amount  of  rest  allowed  to 
them)  in  them  of  the  cholera  bacteria,  thus  at  the  same  time 
tending  to  increase  the  quantity  of  the  produced  toxine  and  the 
general  intoxication  of  the  system,  many  observers  insist  upon 
completely  renouncing  opium  as  a  remedial  agencj^  for  chole- 
raic affections. 

But  my  observations,  as  I  mentioned  above,  were  sufficient 
for  my  formulating  the  following :  I  had  the  opportunity  dur- 
ing the  cholera  epidemics  to  cure  by  moderate  doses  of  opium 
(of  this  later  on)  many  cases  of  diarrhoea,  after  a  preliminary 
evacuation  of  the  intestinal  tract,  or  without  the  same  when 
there  were  no  indications  for  it.  The  exact  nature  of  these 
diarrhoeas  remained  then,  and  remains  now  uncertain :  it  is  just 
as  impossilile  to  assert  that  they  had  all  been  choleraic  diarrhoeas, 
as  that  they  had  not.  In  other,  much  less  frequent,  cases,  not- 
withstanding this  method  of  treatment,  in  conjunction  of  course 
with  the  appropriate  hygienic  measures,  the  diarrhoea  did  not 
stop  and  there  developed  cholerine  or  genuine  cholera. 

With  such  observations  in  view  I  consider  it  erroneous  to 
reject  a  remedy  which  acts  so  successfully  and  so  rapidlj-  in  the 
majority  of  cases  under  discussion,  and  I  recommend,  after  the 
intestines  have  been  evacuated,  to  administer  at  once  to  an  adult 
patient  fifteen  or  twenty  drops  of  the  tincture  of  opium,  and 
later  on,  if  necessary,  in  accord  with  the  effect  of  the  opium  and 
the  course  of  the  disease,  to  give  the  same  in  five-drop  doses 
and  always  in  warm  (boiled)  water,  or  with  the  addition  of 
strong  wine  or  good  clarified  brand}^  The  ordinary  dose  is  from 
thirty  to  forty  or  even  sixty  drops  during  twenty-four  hours. 


—  379  — 

This  treatment  I  usually  continue  for  one,  one  and  a  half,  or  the 
longest,  for  two  days.  And  what  is  to  be  done  next?  In  the 
greater  majority  of  cases,  this  treatment  will  brmg  about  a  ces- 
sation of  the  diarrhoi'a.  In  other,  less  frequent,  cases,  the  diar- 
rhoea is  only  diminished,  but  does  not  cease  altogether,  and 
without  taking  on  in  the  least  the  character  of  a  choleraic  affec- 
tion, it  is  prolonged,  and  shows  an  inclination  toward  becoming 
chronic ;  in  such  cases,  leaving  aside  opium,  I  resort  to  bismuth, 
especially  if  the  large  intestine  become  affected,  or  tra.  coto,  if 
the  small  intestme  is  the  seat  of  the  disease,  or  both  together ; 
I  also  administer  ordmary  clysters,  or  with  bismuth,  tannin 
and  boric  acid.  Finally,  there  are  still  less  frequent  cases  in 
which  the  diarrhoea,  m  spite  of  the  treatment,  becomes  aggra- 
vated, and  the  affection  takes  on  a  choleraic  character.  Then, 
but  not  before  one  or  two  days  of  opium  treatment,  I  set  aside 
the  opium,  principally  because  in  moderate  doses  it  is  ineffective, 
while  the  administration  of  large  doses  is  fraught  with  danger : 
for  such  doses  will  overcome  the  irritant  influence  of  the  chole- 
raic affection  on  the  intestinal  peristalsis,  which  may  result  in 
constipation  —  a  condition  certainly  of  extreme  danger,  and  a 
moderate  diarrhoea  is  by  far  preferable  to  a  non-evacuated  intes- 
tinal tract ;  but  even  if  such  be  not  the  case,  then  in  view  of  the 
possible  approach  of  the  algid  stage,  when  the  nervous  system 
is  most  severely  affected  by  the  choleraic  toxine  (with  the  re- 
sulting thickened  blood  and  a  lack  of  oxygen),  I  consider  it  very 
dangerous  to  still  more  weaken  this  system  by  the  introduction 
of  large  doses  of  opium. 

Havmg  then  set  aside  opium,  I  administer  internally  bismuth 
subnitrate  in  doses  sufficient  to  put  a  stop  to  the  excessive  diar- 
rhoea which  deprives  the  organism  of  so  much  fluid,  namely, 
ten  to  fifteen  grains  at  a  dose,  from  four  to  six  times  a  day ;  I 
recommend  bismuth  as  a  remedy  reliable  in  non-choleraic  diar- 
rhoeas, which  acts  at  the  same  time  as  a  disinfecting  agency,  is 
well  borne  hj  the  intestines  and  does  not  exert  any  deleterious 
effect  on  the  nervous  system,  as  would  be  the  case  from  large 
doses  of  opium. 

But  as  regards  the  expectations  reposed  in  bismuth  as  a 
positive  anticholeraic  agency,  exerting  an  effect  on  the  cholera 


—  380  — 

bacteria  and  their  toxines,  which  effect  would  be  evidenced  by  a 
rapid  and  decided  change  of  the  choleraic  affection  to  the  better, 
these  expectations  were  but  little  substantiated  by  observations, 
just  as  was  the  case  with  calomel,  salol,  etc.  Together  with  the 
bismuth  I  advise  for  patients  suffering  from  the  cholera  affection 
in  the  condition  under  discussion  large  (from  1000  c.  c.  and 
more),  and  hot  (38°  to  40°  C.)  watery  clysters  with  tannin  (one 
per  cent  solution^,  as  recommended  by  the  well-known  Neapol- 
itan clinician  C'antani. 

Cantani  *  in  his  treatment  of  cholera  chiefly  aims :  firf^t,  to 
destroy  the  cholera  bacteria  and  their  toxines  m  the  intestines, 
and  secondly,  to  diminish  the  thickening  of  the  blood  and  to 
assist  in  the  elimination  from  the  organism  of  the  cholera  tox- 
ine  absorbed  by  the  blood. 

To  effect  his  second  purpose  he  recommends  the  introduction 
hypodermicall}^  of  a  solution  of  common  salt  (the  so-called 
hypodermoclysis,  of  which  we  shall  speak  in  connection  with 
the  treatment  of  the  algid  period)  ;  while  for  the  first  purpose 
he  resorts  to  the  above-named  clysters  (enteroclysmata),  in  the 
belief  that  they  may  reach  beyond  the  ileo-ca3cal  valve  (valvula 
Bauhini)  into  the  small  intestine  and  there  exert  an  influence 
on  the  bacteria  and  their  toxines.  I  personally  had  as  yet  no 
opportunity  of  treating  cholera  patients  since  the  time  (1884) 
that  Cantani  called  attention  to  his  method ;  but  there  are 
abundant  proofs  in  the  literature  of  the  subject  which  speak  of 
the  merits  of  Cantani's  treatment:  both  his  own  and  the  en- 
thusiastic reports  of  many  other  Italian  physicians  fell  short  of 
the  expectations  excited,  and  the  percentage  of  deaths  has 
hardly  changed  perceptibly  since  the  introduction  of  this  method ; 
nevertheless,  the  eiiteroclysmata  as  well  as  the  hypodermoclys- 
mata  are  recognized  as  useful  aids  in  the  treatment  of  cholera. 

I'he  principal  effect  of  large  hot  enteroclysmata  consists  in 
tliat  they  communicate  warmth  to  the  body,  which  means  that 
they  communicate  the  exciting  influence  of  the  heat  to  an  or- 
ganism weakened  by  diarrhoea  and  the  cholera  affection  in 
general :  the  diarrhcea  and  the  vomiting  diminish,  the  jDulse 
grows   stronger,  the  self-feeling  becomes   better.     The   entero- 

*  Vide  liis  communication  in  Berl.  Klin.  Wochenschrift,  No.  37,  1892. 


—  381  — 

clysmata  exert  also  some  effect  by  acting  on  the  cholera  bac- 
teria and  their  toxines  in  the  large  intestine,  and  by  removing 
them.* 

What  other  measures,  outside  of  those  enumerated  above, 
must  we  resort  to  in  the  treatment  of  the  affections  under  dis- 
cussion ?  I  refer  of  course  only  to  such  patients  as  enjoyed  fair 
health  up  to  the  time  they  fell  victims  to  cholera  (we  surely 
cannot  touch  here  on  the  treatment  of  persons  afflicted  with 
any  chi-onic  or  aoute  affection  previous  to  their  being  attacked 
with  cholera,  as  that  will  lead  us  too  far).  In  sjLich  patients,  be- 
sides the  intestinal  therapy,  we  must  also  treat  tlie  cardiac  and 
the  general  conditions.  To  combat  these  last  symptoms,  as 
well  as  those  presented  by  the  intestines,  the  chief  measures 
resorted  to,  besides  those  mentioned  above,  (Consist  in  keeping 
the  patient  warm  (as  by  a  warm  bath,  by  covering  the  patient 
well,  and  particularly  hj  keeping  the  abdomen  warm,  and  by 
giving  warm  drinks  —  the  best  is  weak  tea),  and  in  the 
administration  of  alcohol  in  the  form  of  wine,  cognac,  jum  and 
distilled  brandy.  The  hot  baths  (30°  R.  and  higher),  so  useful 
in  the  algid  stage  of  cholera,  are  of  course  unnecessary  in  the  af- 
fections under  consideration :  these  measures  and  the  employ- 
ment of  enteroclysmata,  repeated  as  necessary,  will  keep  the 
patient  sufficiently  warm. 

2.  Cholerine  or  the  period  of  cholera  'proper^  preeeding  the  algid 
stage.  —  The  same  heat-generating  measures  and  the  enteroclys- 
mata employed  repeatedly.  For  internal  use,  as  far  as  vomit- 
ing permits  it,  bismuth  and  alcoholics.  There  are  no  sure 
measures  against  vomiting :  we  try  ice,  ether,  and  in  very  rare 
exceptional  cases,  as,  for  instance,  when  the  vomiting  takes  on 
a  dangerous  character  in  cholera  patients  who  are  afflicted  with 
cardiac  or  arterial  disease,  we  resort  to  hypodermic  injections 
of  morphine  (one-eighth  or  one-fourth  grain  at  a  time)  or  cocaine 
(^.  cocaini  muriatici  gr.  xv,  aquse  destil.  fss).     A  whole  or  one- 

*  (A  later  addition.)  Prof.  Genersich  recently  recommended  washing 
out  the  whole  alimentary  canal  (so  that  the  fluid  introduced  per  anum 
is  ejected  by  vomiting  per  os)  in  cholera  and  other  diseases  (Progres 
Medical  and  Deutsche  Medicinische  Wochenschrift,  189:3).  It  remains 
for  the  future  to  determine  the  value  and  the  application  of  this  method 
of  treatment. 


—  382  — 

half  syringe  at  a  time),  the  introduction  of  which  into  the  or- 
•  ganism,  with  the  consequent  weakening  effect  on  the  nervous  sys- 
tem, is  not  desirable  at  all  in  view  of  the  possible  approach  of 
the  algid  stage. 

But  usually  vomiting,  and  its  effects  on  the  organism,  do 
not  require  the  use  of  such  strong  measures  ;  moreover,  as  men- 
tioned above,  the  enteroclysmata  diminish  the  vomiting  to  an 
extent.  Nor  do  the  cramps  necessitate  the  employment  of 
strong  measures,  such  as  hypodermic  injections  of  morphine. 
The  best  means  for  combating  the  cramps  is  to  immediately  put 
the  affected  part  into  a  position  opposite  to  that  into  which  it 
was  contracted;  most  frequently  the  cramps  take  place  in  the 
muscles  of  the  calves  extending  the  foot;  it  is  sufficient  to 
flex  the  foot  and  the  cramps  cease  ;  however,  as  was  mentioned 
above,  the  cramps  tend  to  rapid  disappearance  by  themselves. 
3.  The  algid  stage  of  cholera  projyer.  —  The  above-named  meas- 
ures contributing  heat,  including  the  enteroclysmata,  also  hot 
baths  :  in  a  general  way  the  body  should  be  kept  warm  by  all 
suitable  means  at  hand.  Later  on,  with  the  first  symptoms 
of  the  approaching  algid  stage,  to  counteract  the  thickening  of 
the  blood,  the  lack  of  oxygen  and  the  anuria,  and  also  to  excite 
by  warmth  the  heart  and  the  nervous  system,  resort  must  be 
had  to  Cantani's  large  (from  300  to  1,000  c.  c.  at  a  time)  hot 
(38  °  to  40°  C.  )  hypodermoclysmata,  containing  a  solution  of 
common  table-salt  (7.5  to  1,000),  injected  into  places  where  the 
skin  is  easily  raised  in  folds  and  the  subcutaneous  layer  affords 
a  convenient  receptacle  for  the  introduced  fluid  (except  in  the 
region  of  the  neck,  into  which  the  introduction  subcutaneously 
of  a  large  quantity  of  fluid  is  known  to  be  fraught  with  dan- 
ger). Usually  after  such  a  hypodermoclysma  has  been  admin- 
istered, the  pidse,  hitherto  hardly  perceptible,  grows  stronger, 
and  the  general  weakness  of  the  patient  diminishes.  It  is 
true  that  this  improvement  does  not  last  long,  and  on  the  hy- 
podermoclysma being  repeated,  it  ■ —  the  improvement  —  is  not  as 
considerable  as  it  was  the  first  time;  nevertheless,  the  value  of 
the  hypodermoclysma  is  beyond  doubt,  and  its  employment  is 
unconditionally  indicated.  The  injection  into  the  veins  of  a 
salt  solution  does  not  offer  any  advantages  over  the  hypoder- 


—   383  — 

moclysmata;  it  is  moreover  applied  with  greater  difficulty, 
unless  it  be  in  the  hospital,  and  besides  is  not  devoid  of  danger. 
Finally,  during  the  algid  stage,  it  is  of  the  greatest  importance  to 
introduce  stimulants  both  internally,  such  as  hot  tea,  the  various 
alcoholics,  ether,  camphor,  and  hypodermically ;  for  this  last 
we  use  oleum  eamphoratum  fortius  (1 :  5),  one  syringeful  at  a 
time,  and  caifeinum  natrobenzoicum,  from  one-third  to  two- 
thirds  of  a  syringeful  (it  is  best  used  thus :  1^..  natri  benzoic!, 
caffeini  aa  3ij,  aquae  destil.  3ss.;  such  a  considerable  concentra- 
tion will  assist  in  keeping  the  solution  in  better  condition,  nor 
will  it  become  turbid).  It  needs  no  explanation  that  both  the 
hypodermoclysmata,  as  well  as  the  hypodermic  injections  of 
the  various  stimulants,  should  be  made  under  the  strictest  anti- 
septic precautions.* 

4.  TJie  period  of  reaction  (typhoid  cholera).  — The  treatment 
of  the  nephritis  caused  by  cholera  consists  in  warm  baths  and 
abundant  drinks. 

The  treatment  of  the  typhoid  and  uraemic  symptoms  :  signs  of 
congestion  (as  a  flushed  face)  require  the  application  of  cold  to 
the  head  or  even  the  application  of  leeches  to  the  root  of  the 
nose,  if  the  patient  is  not  very  weak ;  for  symptoms  indicating 
excitability  of  the  nervous  system  (as  delirium,  etc.)  sodium 
bromide ;  and  for  symptoms  of  nervous  oppression,  moschus 
and  washing  of  the  head  with  fresh  water. 

If  the  body  temperature  be  very  high  (about  -10°  6'.,  104°  i^.) 
small  doses  (three  to  five  grains)  of  phenacetine  or  antifebrine 
will  reduce  it  to  an  extent. 

*  (A  later  note.)  Prof.  Slikliareft'sky  (  "  On  the  Treatment  ot  Cholera 
during  the  Algid  Stage,"  a  reprint  from  Nos.  16  and  17  of  the  South- 
Kussian  Medical  Gazette,  1893)  calls  attention  to  the  long  forgotten,  but 
according  to  the  observations  of  many  physicians,  very  effective  treatment 
of  the  algid  period  of  cholera  by  the  method  of  Dr.  Chapman.  "The 
gist  of  this  method  consists  in  this,  that  with  the  aid  of  cold  or  heat  an 
effect  is  produced  on  the  patient's  spinal  column,  w^hile  the  other  parts 
of  the  body  are  subjected  to  heat  in  the  first  case,  and  to  cold  in  the 
second  by  compresses.  Thus  a  rubber  bag  filled  with  ice  is  placed  along 
the  spinal  column  of  the  patient  during  the  algid  stage,  and  dtiring  the 
typhoid  period  a  similar  bag  is  filled  with  water  at  the  temperature  of 
38°  B."  Considering  the  algid  period  of  cholera  as  an  "  infectious  neuro- 
sis," Prof.  Shkliareffsky  explains  from  this  point  of  view  the  effect  of 
Chapman's  method  of  treatment.  Prof.  Shkliareffsky' s  article  is  full  of 
interesting  points. 


—  384  — 

The  treatment  of  the  various  complications  —  as  erysipelas, 
ulcers,  abscesses  and  diphtheritic  affections  (as  dysentery,  etc.) 
—  is  to  be  conducted  according  to  the  indications  of  these  com- 
plications. 

Having  spoken  thus  far  of  the  genuine  Asiatic  or  India 
cholera,  I  will  now  say  a  few  words  on  cholera  nostras. 

The  attacks  of  this  disease  are  similar  by  their  nature  and 
course  to  those  of  the  genuine  cholera,  and  may  also  occur  with 
a  similar  intensity,  but  are  not  as  extensive  as  these  last: 
cholera  nostras  occurs  only  as  an  endemic,  never  as  an  epidemic 
disease.  The  microbe  which  produces  it  is  as  yet  unknown ; 
they  failed  to  find  the  comma  bacilli  of  the  genuine  cholera  in 
the  evacuation  of  patients  suffermg  from  our  (or  European) 
cholera.  During  the  prevalence  of  this  last  Finkler  and  Pryor 
found  a  bacterium  similar  to,  but  not  identical  with,  the  comma 
bacillus  of  genuine  cholera ;  but  in  the  following  epidemics,  the 
Fmkler-Pryor  bacilli  have  not  been  found.  Last  spring,  there 
occurred  in  the  vicinity  of  Paris  (at  the  beginning  only  there, 
and  at  no  other  place  in  France)  severe  cholera-like  attacks,  but 
without  any  notable  tendency  to  further  spreading.  Consider- 
ing them  of  the  nature  of  cholera  nostras  and  noting  that  they 
occurred  in  the  localities  which  had  formerly  suffered  severely 
from  the  true  Asiatic  cholera,  some  physicians  assumed  that 
cholera  nostras  was  but  a  degenerate  descendant  of  the  Asiatic 
cholera.  The  treatment  of  the  attack  of  cholera  nostras  does 
not  in  the  least  differ  from  that  of  the  genuine  Asiatic  cholera. 


SUPPLEMENTS. 


ON  BLOODLETTING. 


AN  ADDRESS  DELIVERED  AT  THE  ANNUAL  MEETING  OF  THE 
MOSCOW  PHYSIO-MEDICAL  SOCIETY,  JANUARY,  1889. 

G-entlemen :  —  I  propose  to  speak  of  bloodletting  —  a  reme- 
dial measure  the  value  and  importance  of  whicli  an  experience 
extending  over  many  years  taught  me  to  appreciate.  I  shall 
discuss  bloodletting  only  as  applied  in  the  doraam  of  internal 
medicine,  without  touching  on  its  use  in  surgery,  gynaecology, 
pediatrics,  etc. 

This  is  not  the  place  to  dilate  on  the  history  of  bloodletting, 
which  begins,  probably,  with  the  history  of  medicine  itself.  I 
shall  only  touch  on  that  period  m  its  history,  of  which  I  have 
been  an  eye-witness  myself;  I  shall  do  that,  that  I  may  show 
how  my  own  experience  was  formed  concerning  the  employ- 
ment of  this  measure.  During  my  student  years  and  my  three 
years'  clinical  assistantship,  bloodletting,  general  as  well  as  local, 
was  resorted  to  frequently  and  unsparinglj^ :  the  influence  of 
Broussais  was  as  yet  prevalent,  although  not  strongly,  and  I 
must  add,  to  a  constantly  diminishing  extent.  I  visited  later, 
in  1856,  Western  Europe,  and  found  there  a  complete  reaction 
against  venesection,  both  in  literature  and  in  practice  :  during 
my  three  years'  sojourn  there,  I  did  not  see,  in  any  of  the  clinics 
in  Germany,  Austria  and  France,  the  employment  of  bloodlet- 
ting, and  only  very  rarely  indeed  did  I  witness  the  use  of  cup- 
ping-glasses and  leeches.  On  my  return  to  Moscow,  I  also 
found  here  the  beginning  of  a  similar  reactionary  movement, 
which  resulted  in  this,  that  eight  or  ten  years  later  a  similar 
negative  stand  was  taken  against  the  employment  of  bloodlet- 
ting in  practice  (I  do  not  speak  of  my  own),  as  obtained  at 
that  period  in  Western  Europe,  as  well  as  in  England. 

Let  us  consider  the  position  occupied  by  this  subject  at 
the  present  time.  In  Western  Europe  we  hear  complaints  of 
the  unjust  condemnation  and  neglect  with  which  the  subject  of 
bloodletting  is  being  treated ;  and  from  such  men  as,  for  in- 
stance, in  England,  Fen  wick,  Broadbent  and  Oliver;  in  France, 

387 


—  388  — 

Hayem ;  in  Germany,  the  well-known  clinical  teachers  and 
authors  of  special  pathology  and  therapeutics,  Liebermeister, 
Striimpell,  and  Eichhorst.  As  all  these  complain  of  neglect, 
this  seems  to  be  continuing.  Liebermeister,  Striimpell  and 
Eiclihorst  recommend  bloodletting,  but  they  do  not  give  any 
sufficiently  clear  indications  for  its  emplojanent,  thus  showing 
but  a  poor  personah  experience.  Eegarding  these  same  recom- 
mendations it  is  interesting  to  note  the  opinion  of  another  clini- 
cal teacher  and  author  of  a  text-book  of  special  pathology  and 
therapeutics,  Jiirgensen,  who  confesses  openly  to  being  sceptical 
towards  bloodletting,  and  who  expresses  himself  as  follows : 
"  Personally  I  am,  perhaps,  too  much  afraid  of  blood,  and  I 
will  therefore  rather  not  enter  my  opinion."  *  He  further 
makes  a  statement,  which  is  evidently  intended  for  Liebermei- 
ster, Striimpell  and  Eiclihorst,  authors  of  the  most  widel}^  read 
text-books  of  special  pathology  and  therapeutics,  to  this  effect : 
"  We  observe  a  tendency  m  our  text-books  of  to-day  not  to 
wholly  neglect  the  use  of  bloodletting,  even  if  the  author  in  his 
practice  does  not  employ  it  at  all,  or  very  rarely."  | 

As  regards  medical  practice  with  us,  with  the  exception  of 
Moscow  and  the  ph3^sicians  who  are  the  followers  of  Moscow 
methods  in  medicine,  everywhere  else,  in  the  principal  med- 
ical centres,  the  university  cities,  as  well  as  in  the  regions 
embraced  by  their  influence,  bloodletting,  and  abstraction 
of  blood  in  general,  is  looked  upon,  as  far  as  I  know,  with 
disfavor.  I  am  unable  to  bring  before  you  any  literary  ma- 
terial on  the  subject,  as  I  am  not  aware  of  the  existence  of 
any  such ;  but  as  far  as  is  known  from  practice,  the  stand  taken 
against  bloodletting  is  of  a  pronouncedly  negative  character,  at 
least  up  till  now,  in  the  above-named  localities.  Thus,  for  in- 
stance, a  patient  from  a  provmoial  city  who  applied  a  few  leech- 
es by  the  advice  of  his  physician,  a  graduate  of  the  Moscow 
University,  and  who  was  considerably  relieved  by  them,  later 
on,  while  consulting  a  University  professor,  not  in  Moscow, 
heard  him  ask,  after  inquiring  about  his  disease  and  the  treat- 
ment,  "  Whoever  uses  leeches  now  ?  "     Or  another  example  :  a 

*  Ziemssen,  Handbucli  d.  allgemeinen  Therapie,  I.  B.,  2  ii.  3  Th.,  An- 
tiplilogistisclie  Heilmetlioden  v.  Jiirgensen,  S.  159:  "  Ich  fiirineine  Person 
bin  vielleiclit  iibertrieben  blutsclieu  iind  mochte  daher  mit  meinem  Ur- 
tlieil  zuriickhalteu." 

t  Ibidem,  S.  219:  "Man  erkennt  in  unseren  heutigen  Lelirbiichern  das 
Bestreben  die  Blutentzieliung  uicht  ganz  fallen  zu  lassen,  audi  dann, 
wenn  der  Verfasser  in  praxi  seltenen  oder  gar  keinen  Gebraucli  davon 
macht." 


—  389  — 

patient,  who  was  suffering  with  pain  in  the  stomach  and  with 
nausea  due  to  extreme  hypereemia  of  the  liver  caused  partly  by 
weak  cardiac  activity,  partly  by  abuse  of  wine,  and  who  has 
been  taking  various  drugs  without  any  relief,  called  in  the  aid 
of  a  Moscow  physician.  This  last  ordered  leeches  to  the  coccy- 
geal region  :  on  the  very  next  day  the  above-named  sufferings 
disappeared,  without  in  the  least  weakening  the  patient.  One 
month  later  the  patient  returns  to  his  constant  place  of  resi- 
dence, and  tells  his  former  physician,  a  clinical  professor,  of  the 
improvement  in  his  health,  whereat  this  last  remarks  :  "  But 
this  improvement  is  only  temporary."  Patient  however  replies  : 
•'  Whether  temporary  or  not,  I  cannot  say,  but  I  appreciate  it 
dearly,  whereas  the  former  medicinal  means  have  not  done  for 
me  even  that  much."  (3r  here  is  another :  a  patient,  who  at 
the  advice  of  his  physician,  a  Moscow  man,  applied  leeches  and 
was  relieved  by  them,  was  asked  by  another  doctor,  not  from 
Moscow,  as  to  the  age  of  his  physician.  When  told  that  he  — 
the  physician  —  was  thirty  years  of  age,  he  observed  :  "  I  thought 
he  was  seventy  years  old,  as  he  employs  such  ancient  remedies.'" 
I  had  occasion  to  hear  a  great  many  similarly  expressed  opinions ; 
l)ut  I  have  not  heard  such  as  would  favor  the  employment  of 
bloodletting.  It  is  also  curious  to  note,  that  the  unfavorable 
opinions  come  from  persons,  who  have  never  employed  blood- 
lettmg,  and  who  therefore  had  no  personal  experience  with  this 
method  of  treatment. 

Turning  now  to  Moscow  and  the  region  influenced  by  its 
teachings,  I  will  first  of  all  touch  upon  my  j^ersonal  relation  to 
the  subject  under  discussion.  As  I  said  before,  during  my 
student  years  and  my  clinical  service,  l^loodletting  was  prac- 
tised frequently  and  unsparingly,  so  that  I  had  many  an  oppor- 
tunity to  witness  its  undoubted  value,  when  it  could  not  be  re- 
placed in  many  cases,  while  in  others  I  also  saw  great  harm 
caused  by  it.  Of  course,  only  later  on,  as  my  practical  experi- 
ence began  to  mature,  did  I  learn  to  appreciate  with  greater 
exactness  its  beneficial  as  well  as  its  harmful  effects.  The 
errors  of  the  medical  practice  of  those  times  consisted  in  this, 
that  it  was  taught  that  bloodlettmg  would  cure  diseases  —  "  the 
inflammations"  —  considering  as  an  inflammation  pneumonia, 
acute  articular  rheumatism,  etc. ;  consequently,  without  taking 
into  account  the  condition  of  the  patient's  strength,  they  re- 
sorted not  only  to  one,  but  to  repeated  bloodlettings  (the  so- 
called  ''  coup  sur  coup"  of  Bouillot),  not  curing  the  disease,  but 
debilitating  the  patient,  thus  increasing  to  a  fatal  extent  the 


—  390  — 

conditions  favoring  a  bad  termination  of  the  disease.  Another 
cause  of  the  unfortunate  employment  of  bloodletting  was  to  be 
found  in  the  imperfectness  of  diagnostic  skill  at  those  times : 
thus,  for  instance,  in  headache,  in  which  out  of  ten  cases  we 
will  probably  in  one  resort  to  bloodletting  in  the  coccygeal 
region,  we  then  did  it  if  not  in  all  the  ten,  surely  in  nine,  and 
we  did  not  put  five  to  eight  leeches  as  is  done  now,  but  from 
ten  to  twenty  and  more.  As  one  of  the  harmful  influences  of 
those  times  must  be  considered  the  universal  custom  of  the 
laitj^  to  resort  to  local,  and  at  times  even  to  general  bloodletting 
without  the  physician's  advice,  a  custom  which  fortunately  does 
not  exist  at  the  present  time,  thanks,  we  must  openly  confess, 
to  the  negative  stand  taken  by  the  medical  profession  toward 
the  subject  of  bloodletting. 

But  I  must  say  again,  that  at  the  same  time,  at  the  beginning 
of  my  medical  career,  1  had  occasion  to  observe  the  undisputed 
benefit  from  bloodletting  and  even  the  impossibility  of  replac- 
ing it,  and  I  therefore  never  left  off  this  method  of  treatment ; 
but  in  accord  with  my  experience  extending  over  many  years, 
with  the  continually  developing  medical  maturity  and  the  rapid 
progress  in  the  domain  of  diagnosis,  general  pathology  and 
therapeutics,  I  worked  out  a  different  practice  of  bloodletting. 
As  regards  the  practice  in  Moscow,  1  can  remember  the  time  — 
the  acme  of  the  period  of  opposition  to  bloodletting  —  when  I 
met  almost  no  colleagues  who  resorted  to  bloodletting  as  a 
derivative  measure,  and  I  had  to  defend  my  position  when 
advising  its  application  in  consultations.  At  the  present  time 
the  matter  stands  otherwise :  my  own  practice  and  that  of  a 
number  of  the  attending  physicians  at  my  clinic,  as  well  as 
personal  assistants  who  became  later  on  independent  practi- 
tioners and  partly  also  clinical  instructors,  have  brought  it  about 
that  the  employment  of  bloodletting  as  a  derivative  measure 
in  the  wsij  1  am  applying  it,  has  become  firmly  established  in 
Moscow  and  the  circle  of  its  medical  influence. 

I  will  explain  now  the  method  used  in  my  present  prac- 
tice of  bloodletting.  I  shall  be  concise,  as  I  intend  to  speak 
only  of  what  is  proved  by  facts  to  be  certain,  without  touch- 
ing upon  theories  which  explain  and  prove  the  benefit  de- 
rived from  bloodlettmg.  In  the  present  condition  of  physi- 
ology and  pathology  such  theories  are  as  yet  impossible :  there 
exists  no  theory  that  could  not  be  contradicted  ;  and  in  doing 
this,  there  is  always  a  danger,  —  to  be  sure,  only  when  the 
subject   is  but  superficially  discussed,  —  while  disproving  the 


—  391  — 

theory  on  which  the  facts  are  based,  to  consider  also  these  last 
as  refuted.  My  conviction  regarding  the  benefit  of  bloodlet- 
ting as  based  upon  facts  has  been  reached  by  the  same  method 
of  analyzing  and  criticising,  as  my  personal  conviction  of  the 
benefit  derived  from  any  other  indisputably  efficient  remedial 
agencies  of  our  therapy. 

With  every  bloodletting  there  takes  place  a  more  or  less 
considerable  depletion  of  the  circulatory  system:  this  effect  of 
bloodletting  surely  no  one  will  deny.  The  so-called  derivative 
effect  of  bloodletting  i«  not  recognized  by  all :  I  am  personally 
convinced  of  this  last  effect,  and  I  will  explain  later  on  what  I 
mean  by  it  and  will  show  wh}^  I  believe  in  it. 

I.  Bloodletting,  tvTiere  the  chief  effect  is  depletion,  although 
at  the  same  time  there  may  he  also  derivation. 

Venesection  is  resorted  to  by  me,  when  in  disturbances  of 
the  brain  or  chest  circulation  there  occurs  a  vital  indication, 
i.  e.  an  indication  to  save  the  life  from  threatening  death  ;  this 
occurs  m  the  following  most  important  cases. 

Disturhanees  of  the  cerebral  circulation.  —  1.  In  the  presence 
of  evident  symptoms  of  a  threatenmg  or  an  inevitable  cerehral 
apoplexy  in  patients  with  atltermatous  arteries.,  usually  caused 
by  rupture  of  the  cerebral  arteries  :  in  embolism  and  thrombosis 
the  indications  for  bloodletting  are  much  less  frequent.  I  must 
say  here  a  few  words  concernmg  the  condition  of  the  pulse. ' 
Bloodletting  m  such  cases  is  to  be  done  not  only  when  the 
pulse  is  full  and  strong,  but  also  if  it  be  weak,  as  long  as  we 
have  to  do  with  a  patient  who  is  not  anaemic.  Let  me  say,  that 
the  majority  of  patients  present  the  following  appearance ;  the 
pulse  is  weak,  but  the  patient's  nutrition  is  in  a  good  condition, 
he  does  not  look  anaemic,  rather  plethoric,  and  the  inquiry 
from  among  the  surrounding  friends  elicits  the  fact,  that  the 
patient  enjoyed  a  good  appetite  and  digestion,  has  never  suffered 
from  any  loss  of  blood,  has  usually  complained  of  feeling  warm 
and  not  chilly,  etc.  In  such  cases  the  small  pulse  points  not  to 
anaemia,  but  to  a  weak  condition  of  the  cardiac  muscle,  name- 
ly of  the  left  ventricle,  or  to  a  disturbance  of  the  innervation 
of  the  heart,  which  in  its  turn  may  be  due  to  the  disturbance 
of  the  cerebral  circulation,  which  occasioned  the  apoplectic 
condition.  Here  we  must  employ  bloodlettmg  and  administer 
at  the  same  time  stimulants  per  os  or  hypodermically :  frequent- 
ly at  once  after  or  even  during  the  bloodletting,  the  pulse 
becomes  fuller  and  stronger.     Bloodletting  in  these  as  well  as 


—  392  — 

in  the  cases  which  will  be  spoken  of  later,  should  always  be 
•performed  in  the  presence  of  a  physician.  As  regards  the 
amount  of  blood  to  be  abstracted,  in  this  as  in  other  cases, 
I  abstract  from  adults  twelve  ounces,  but  frequently,  guided 
by  the  condition  of  the  constitution,  nutrition  and  hsemato- 
poiesis  of  the  patient  and  other  peculiarities  of  the  given  case, 
eight  or  six  ounces. 

2.  In  the  presence  of  evident  symptoms  of  threatening  or 
already  occurring  cerebral  a'poplexy  in  fatient^  ivith  a  chronic  ne- 
phritis and  hyjjertrojjliy  of  tJie  left  venti-icle.  The  text-books  often 
recommend  bloodletting  in  the  treatment  of  urtemia,  but  they 
fail  to  give  any  definite  indications,  the  absence  of  which  among 
the  recommended  therapeutical  measures  forms,  however,  the 
usual  weak  point  of  many  a  text-book.  In  a  given  case  it 
may  lead  the  young  physician  into  committing  a  fatal  error, 
namely:  if  with  the  urpemic  symptoms  there  are  also  present 
signs  of  threatening  cerebral  apoplexy,  and  with  these  there  is 
a  full  and  strong  pulse  because  of  a  hypertrophy  of  the  left 
ventricle,  a  flushed  face,  etc.,  then  we  must  of  course  employ 
bloodletting ;  but  if  the  symptoms  of  threatening  apoplexy  are 
absent,  if  the  face  is  pale,  the  pulse  weak,  and  if  there  is  consider- 
able oedema,  then  bloodletting  may  harm  the  patient  greatly, 
if  it  does  not  directly  kill  him  by  hastening  the  development 
of  cerebral  (edema.  In  such  a  case  we  should  not  resort  to 
bloodletting,  l)ut  we  should  administer  stimulants,  and  prin- 
cipally calomel,  as  a  laxative  and  diuretic  remedy  whose  effect 
diminishes  directly  the  ursemic  poisoning  of  the  blood. 

Disturbances  of  the  circulation  ivithin  the  chest. 

1.  There  occur  cases,  though  rarely,  of  diseases  of  the  heart., 
most  frequently  with  stenosis  of  the  left  venous  openmg,  when 
the  patient,  as  yet  not  anaemic  and  generally  not  exhausted, 
presents  a  condition  of  extreme  disturbance  of  the  cu-culation, 
principally  of  the  pulmonary,  as  evidenced  hj  severe  dyspnoea 
and  by  hsemoptysis,  and  of  the  portal,  as  seen  by  the  enlarge- 
ment and  sensitiveness  of  the  liver :  here  we  have  no  time  to 
wait  for  the  effects  of  remedies  which  regulate  the  cardiac 
activity  and  the  circulation  ;  besides,  the  best  of  them,  namely 
digitalis,  is  at  times  badly  borne  in  such  cases  and  acts  slowly : 
it  is  slowly  absorbed,  as  you  can  easily  comprehend,  on  account 
of  the  overfilling  by  blood  of  the  liver,  and,  consequently,  also 
of  the  stomach.  Here  we  must  employ  bloodletting,  adminis- 
ter stimulants  (as  the  pulse  is  usually  weak)  —  at  times  calo- 
mel, if  there  be  an  mdication  for  it,  —  and  later  on  digitalis, 


—  393  ^ 

which  by  this  time  will  usually  he  well  borne  and  Avill  exert  its 
favorable  effects. 

2.  There  are  cases,  though  not  frequent  ones,  presenting  a 
tumultuous  onset  of  croupous  pneumonia,  when  there  becomes 
affected  at  once  a  considerable  portion  of  one  lung,  and  simultane- 
ously with  this,  in  view  of  the  embarrassed  circulation  in  the 
affected  lung,  there  appears  an  oedema  of  the  other  healthy 
lung,  which  spreads  rapidly,  and  is  accompanied  at  times  by 
haemoptysis.  If  the  patient  is  not  old,  and  is  possessed  of  a 
sound  constitution  and  has  enjoyed  good  health  before  he  was 
attacked  by  the  pneumonia,  then  we  must  do  bloodletting  ;  if 
the  pulse,  as  happens  rather  unfrequently,  be  weak,  then  we 
must  certainly  administer  simultaneously  stimulants.  The  text- 
books usuallj'  recommend,  after  explaining  that  the  oedema  of 
the  lungs  depends  on  the  weakened  cardiac  activity,  for  treat- 
ment stimulants,  and  for  the  relief  of  the  right  ventricle  blood- 
lettmg  from  the  overfilled  venous  half  of  the  circulation. 

Again  I  must  point  to  such  a  want  of  precision  in  the  indica- 
tions, in  recommending  in  such  a  general  way  bloodletting  for 
pulmonary  oedema.  If  we  deal  with  a  case  as  described  above, 
then  we  must  of  course  abstract  some  blood.  But  if  we  have 
a  case  of  pulmonary  cedema  which  appeared  at  the  termination 
of  an  attack  of  croupous  pneumonia,  after  the  seventh  or 
eighth  day  and  later,  in  a  patient  already  debilitated  and 
presenting  symptoms  of  collapse,  then  we  should  not  resort 
to  bloodletting,  a  rather  risky  procedure  in  such  a  case,  but 
we  must  administer  stimulants,  resort  to  large  blisters  and  to 
the  use  of  senega.  However,  as  regards  the  recommendation 
by  the  text-books  of  bloodletting  for  pulmonary  oedema  we 
cannot  help  recalling  to  our  mmd  agaui  the  observation  of 
Jiirgensen,  that  the  authors  of  the  text-books  recommend 
bloodletting,  but  never  employ  it  themselves. 

Local  Bloodletting,  cupping-glasses  with  scarification,  and 
leeches,  are  employed  Ijy  me  with  the  aim  in  view  of  depleting 
the  blood-vessels,  m  the  followmg,  most  frec^uent,  cases. 

1.  In  acute  pleuropneumonia  and  acute  pleurisy.  —  In  pure 
pericarditis  uncomplicated  by  a  pleurisy  of  any  considerable 
extent,  the  resort  to  bloodletting  is  rather  rare :  the  therapeutic 
indication  can  usually  be  fulfilled  by  a  large  blister.  2.  In 
acute  nephritis.  3.  In  acute  inflammation  of  the  great  nervous 
trunks,  principally  of  the  sciatic  nerves — as  in  ischias  ex 
neuritide  acuta.  For  all  these  enumerated  cases,  I  employ 
cuppmg-glasses  with  scarification,  not  leeches.     I  prefer  them 


—  394  — 

to  leeches  in  all  cases  in  .which  the  local  conditions  permit  their 
employment  —  for  the  foUowmg  reasons :  theii-  application, 
as  well  as  their  effect,  is  more  rapid ;  bleeding  stops  at  once 
after  the  cups  are  taken  off,  and  there  is  no  consequent  bleed- 
ing, so  that  we  are  enabled  to  extract  the  desired  amount  of 
blood  with  greater  exactness  without  weakening  the  patient, 
as  happens  frequently  with  leeches  after  which  it  is  difficult  to 
stop  the  bleeding,  and  there  may  occur  more  bleeding  later  on  ; 
the  depleting  effect  is  also  accompanied  by  derivation,  which  is 
greater  than  in  the  case  of  leeches,  and  which  is  also  beneficial  in 
the  above-enumerated  cases  ;  finally  cupping-glasses  with  scari- 
fications are  cheaper  than  leeches  and  require  less  care  on  the 
part  of  the  patient  after  they  are  applied. 

The  number  of  cupping-glasses  for  the  above-considered 
cases  is  usually  six.  seldom  four,  at  times  eight ;  this  last 
number  may  be  employed,  for  instance,  in  pleuropneumonia, 
when  to  the  pleuritic  phenomena,  such  as  severe  pains  in  the 
side  embarrassing  breathing,  and  therefore  increasing  the  dysp- 
noea, which  is  itself  caused  by  the  pneumonia,  there  are  super- 
added symptoms  of  a  tempestuous  attack  of  pneumonia  with 
a  simultaneous  ( edema  of  the  other  healthy  lung,  —  symptoms, 
which  were  spoken  of  above,  in  touching  on  bloodletting ;  in 
such  cases,  which  are  not  clearly  defined,  cupping  may  replace 
bloodletting. 

Local  abstraction  of  blood,  namely,  as  I  said  before,  wet 
cups,  are  resorted  to  by  me  in  the  above-mentioned  cases  in  the 
presence  of  the  following  conditions  :  when  the  patient  has  not 
as  yet  become  weakened,  therefore  usually  only  at  the  begin- 
ning of  the  disease,  during  the  first  two  or  three  days ;  in 
ischias  ex  neuritide  also  later  ;  if  the  local  symptoms,  especially 
the  pains,  are  severe  and  far  advanced.  As  regards  pleuritis 
I  must  say  that  with  it  also  bloodletting  is  indicated  principally 
by  the  acuteness  of  the  attack  when  the  patient's  condition  is 
as  yet  not  weakened,  and  not  by  the  causation  of  the  pleurisy : 
to  be  sure,  we  are  much  more  frequently  compelled  to  do 
bloodletting  for  pleurisy  caused  by  a  cold,  or  for  pleurisy  of 
a  pneumonic  nature,  than  for  purulent  or  tuberculous  pleurisy  ; 
but  these  two  forms  of  pleurisy  do  not  by  any  means  present 
an  absolute  contraindication  to  local  bloodletting.  The  eft'ect 
of  bloodletting  is  usually  manifested  by  the  diminution  of  the 
excruciating  pains  and  the  dyspnoea  in  cases  of  chest  troubles, 
by  the  improvement  in  the  condition  of  the  urine,  in  acute 
nephritis,  by  the  decrease  of  the  febrile  condition,  by  the  more 


—  395  — 

quiet  sleep,  and — as  I  can  attest  from  mv  own  observations 
—  by  a  more  favorable  consequent  course  of  the  disease. 

Where  are  the  cups  to  be  applied  ?  In  the  above-enumer- 
ated diseases  of  the  chest  they  are  usually  apj^lied  to  the 
posterior  and  lateral  surfaces  of  the  thorax ;  hi  nephritis  to 
the  back,  in  the  region  of  the  kidney ;  in  ischias  ex  neuritide, 
on  the  buttocks,  some  four  or  five  cupping-glasses  of  medium 
size  around  the  incisura  ischiadica,  leaving  the  central  part  for 
the  Spanish  fly,  which  must  usually  be  applied  soon  after, 
a  few  hours  after  the  bloodletting.  I  do  not  thmk  that  this 
last  procedure  is  a  trifling  affair :  m  ischias  ex  neuritide  a 
large  fly  exerts  its  best  effect  when  applied  to  the  sides  of  the 
incisura  ischiadica  and  to  its  circumference,  and  especially  if 
it  be  applied  soon,  in  a  few  hours  after  the  bloodletting.  But 
if  there  be  scattered  over  the  part  several  incisions  over  the 
above-named  region,  as  a  result  of  the  inaccurate  directions 
of  the  physician,  and  to  apply  a  fly  directly  on  these  Avould 
be  extremely  painful  and  would  tend  to  cantharis  poisoning, 
then  we  must  either  wait  or  apply  the  fly  to  another  place ; 
in  either  of  which  cases  the  patient  gains. 

In  connection  with  this  I  cannot  help  observing,  that  in  a 
general  way,  due  attention  is  often  not  paid  to  the  mtelligent 
treatment  of  the  surface  of  the  body  at  the  afl:ected  place,  and 
it  —  the  surface  —  is  exploited  rather  thoughtlessly,  forgetting 
that  it  is  on  this  surface  and  with  its  assistance,  that  we  are 
sometimes  compelled  to  withstand  the  last  positive  struggle 
against  the  disease. 

Thus,  for  instance,  in  the  various  chest  affections  dry  cups 
are  applied  over  the  chest  to  effect  a  relief  from  dyspnoea- — 
a  relief  usually  of  but  a  slight  nature  and  short  duration  —  and 
these  are  at  times  applied  in  such  numbers  and  with  such  im- 
moderate zeal,  that  at  the  decided  hour,  when  the  consulting- 
physician  is  usually  called  m.  —  in  case  for  instance,  an  (jedema 
of  the  lungs  is  developed,  and  the  jDatient  can  be  saved  onl}'  by 
the  aid  of  stimulants,  by  senega,  and  principally,  by  large  flies 
applied  to  the  chest  (if  applied  to  any  other  portion  of  the  bodj', 
we  cannot  obtain  even  a  shadow  of  that  effect),  —  the  chest  is 
seen  to  be  covered  by  so  many  severe  ecchymoses  resulting  from 
dry  cupping,  that  there  is  no  place  over  it  even  for  a  small  fly, 
whereas,  as  we  said,  we  must  apply  a  large  one,  and  usually 
more  than  one.  The  same  may  be  said  of  pamting  the  skin 
with  the  iodine  tincture,  which  is  just  as  little  useful  in  the 
above-named  cases  and  which,  later  on,  serves  as  an  obstacle  to 
the  application  of  Spanish  flies. 


—  396  — 

4.  For  local  blood-extraction  with  depletion  in  view  in  dis- 
eases of  the  abdomen,  usually  in  circumscribed  peritonitis  (most 
frequentl}^  for  perityphlitis,  at  times  for  pericystitis  of  the  gall- 
bladder). I  resort  to  leeches  (as  cupping  is  inconvenient  over 
the  abdomen),  from  six  to  ten  in  number. 

Of  local  depleting  bloodletting  —  the  application  of  leeches 
—  in  the  region  of  the  head,  I  shall  speak  later,  for  convenience 
of  exposition,  in  connection  with  derivative  bloodletting. 

II.  Bloodletting,  -where ^  altJiough  there  is  also  depletion,  the 

PPvES^ClPAL  EFFECT  IS  THAT  OF  A  DERIVATIVE. 

To  clearly  elucidate  what  I  mean  by  derivative  bloodletting. 
I  must  first  say  a  few  words  on  the  subject  of  hgemorrhoids. 

AVhat  are  haemorrhoids  ?  And  does  there  exist  in  reality  a 
morbid  condition  which  must  be  distinctively  named  "  haemor- 
rhoids "  ?  The  ancient  medical  works  devoted  much  space  to  the 
subject  of  haemorrhoids.  Later  the  criticism  of  the  views  of  the 
ancient  writers  resulted  in  a  complete  rejection  of  the  same,  so 
that  for  some  time  haemorrhoids  were  not  treated  of  by  any  text- 
books on  pathology.  At  the  present  time  they  again  begin  at 
least  to  speak  of  the  symptoms  peculiar  to  this  condition,  even 
if  they  do  not  consider  it  as  an  independent  morbid  state :  thus 
the  text-book  of  Eichhorst,  the  only  one  of  all  the  modern  Ger- 
man text-books  of  pathology,  in  describing  the  diseases  of  the 
rectum  and  anus,  describes  haemorrhoidal  molumina  preceding- 
haemorrhages  from  the  back  passage,  and  consequently  haemor- 
rhoidal phenomena  are  alluded  to  in  this  connection  as  a  pe- 
culiarity of  the  above-named  local  affections.  I  held  similar 
views  at  the  beginning  of  my  medical  practice,  assuming, 
namely,  that  there  exist  no  haemorrhoids  as  a  morbid  con- 
dition of  an  independent  nature,  and  withal  of  a  general  character, 
but  that  all  so-called  haemorrhoidal  symptoms  are  but  deter- 
mined by  certain  diseases  of  the  rectum  and  anus  in  the 
presence  of  an  impeded  circulation  in  the  portal  system,  as 
caused  hy  constij)ation,  intestinal  meteorism,  abdominal  obesity. 
hepatic  diseases,  etc.  But  experience  taught  me  otherwise  :  it 
proved  that  haemorrhoids  constituted  a  morbid  condition  by  it- 
self, totally  independent  of  diseases  of  the  rectum,  anus  or  the 
abdomen  in  general ;  that  it  may  be  seen  in  connection  with 
these,  as  well  as  with  diseases  of  any  other  parts  of  the  organ- 
ism, but  it  may  also  occur  without  these,  in  their  complete 
absence ;  in  fact,  it  is  more  frequently  absent,  when  these 
affections  are  present.  This  morbid  condition  determines  the 
periodical  appearance  of  morbid  attacks  in  the  head,  spine,  chest 


—  397  — 

and  abdomen,  which  take  on  a  more  or  less  I'apid  or  slow  devel- 
opment, and  wliich  dmippear  suddenly  with  the  appearance  of 
haemorrhage,  at  times  from  the  nose  (more  frequently  in  child- 
hood and  boyhood),  less  frequently  from  the  chest,  i.  e.  haemop- 
tysis (more  often  in  youth),  but  most  frequently  of  a  •'  haemor- 
rhoidal  "  character,  from  the  back  passage.  The  nature  of  the 
appearance  and  of  the  disappearance  of  the  attacks  is  distmctly 
angioneurotic,  peculiar  to  other  neuroses  of  the  circulatory 
system,  such  as  migrame.  urticaria  and  others,  and  I  there- 
fore consider  haemorrhoids  as  an  angioneurosu. 

Here  is  the  fost  case,  which,  together  with  similar  ones 
later  on.  led  me  to  formulate  my  idea  about  the  nature  of  hge- 
morrhoids.  The  patient  tells  me  that  when  a  boy  he  suffered 
with  nose-bleed  which  was  preceded  by  headaches  and  a  flushed 
face  :  with  the  bleeding  the  headache  would  disappear.  When 
a  youth  he  had  slight  haemoptysis.  Imt  unaccompanied  with 
any  constant  cough  or  generally  with  any  constant  attacks  in 
the  chest. 

Patient  is  now  forty  years  old  :  he  is  of  a  robust  constitution, 
with  an  entirely  healthy  chest.  He  complams  of  periodic  ma- 
laise :  there  appear  heaviness  in  the  head,  pain  in  the  neck, 
disturbed  sleep,  gloomy  and  irritable  mental  state,  and  indispo- 
sition to  work;  he  experiences  pains  along  the  spinal  column, 
especially  in  the  lumlmr  region,  a  feeling  of  oppression  in  the 
chest  and  palpitation,  intestinal  pains,  and  the  stool  is  some- 
what difficult ;  then  there  appears  haemorrhage  from  the  back 
passage  and  all  the  symptoms  vanish.  Outside  of  these  attacks, 
which  occur  three  or  four  times  during  the  course  of  the  year, 
and  last  one  or  two  weeks,  and  which  hinder  him  in  his  occu- 
pation, the  patient  is  entirely  healthy  and  does  not  present  abso- 
lutely any  morbid  symptoms  either  in  the  rectum  and  anus  or 
in  the  abdominal  organs  in  general,  or  in  an}-  other  part  of  the 
organism. 

Such  cases  of  pure,  uneomp>licated  hcemorrltoids  are  certaml}^ 
very  rare  :  during  the  thirty-nine  years  of  my  practice,  I  have 
seen  only  about  twenty.  I  must  however  state  here,  that  if 
the  symptoms  of  such  uncomplicated  haemorrhoids  be  less  pro- 
nounced, they  are  usually  borne  without  difficulty,  not  forming 
a  sufficiently  strong  reason  for  calling  in  the  assistance  of  the 
doctor.  While  the  cases  of  haemorrhoids  to  be  seen  together 
with  other  morbid  states  of  the  abdominal  as  well  as  of  any 
other  organs,  are  far  from  being  rare :  in  these  mutually  com- 
plicating each  other  morbid  conditions,  it  is  at  times  possible  to 


—   398  — 

distingiiisli  which  part  of  the  attack  is  to  be  referred  to  the 
haemorrhoids,  and  which  is  to  be  ascribed  to  other  causes ;  but 
at  times  they  are  so  intermingled  that  it  is  impossible  to  effect 
this  distinction. 

The  cause  of  haemorrhoids  is  to  be  looked  for  m  the  inborn 
peculiarity  of  the  organism.  This  is  indicated  by  the  ordinaril}^ 
observable  hereditary  predisposition  to  haemorrhoids,  as  well  as 
by  the  absence  of  other  causative  agencies.  In  the  above- 
named  cases  of  pure  haemorrhoids  I  failed  to  find  such  agencies 
either  in  the  condition  of  the  organism  itself  or  outside  of  it : 
nor  did  these  cases  present  the  effect  of  causes  which  increase 
the  inborn  predisposition  to  haemorrhoids,  causes  which  I  shall 
touch  upon  later  on.  As  regards  the  condition  of  the  haema- 
topoietic faculties  in  persons  presenting  symptoms  of  pure 
haemorrhoids,  some  could  be  considered  as  plethoric,  others, 
again,  as  anaemic,  while  the  majoritj^  presented  all  the  signs 
of  normal  haematopoiesis.  I  may  add  that  some  of  the  above- 
named  cases  of  uncomplicated  haemorrhoids  presented  also  other 
phenomena  of  angioneurotic  nature  (such  as  migraine  and  urti- 
caria), and  quite  frequentl}^  the  coincident  occurrence  of  the 
haemorrhoidal  bleeding  with  the  menstrual  flow  —  an  angio- 
neurotic process:  in  cases  of  pure,  as  well  as  of  complicated 
haemorrhoids  in  women,  the  haemorrhoidal  bleeding  takes  place 
most  frequently  during  or  immediately  after  the  menstruation, 
and  also  immediately  before  it.  Of  the  influences  which  in- 
crease the  predisposition  to  haemorrhoids,  the  use,  or  even 
more,  the  abuse,  of  alcoholic  drinks  is  evidentl}^  one,  and  quite 
likely  a  sedentary  life  and  immoderate  horseback  riding,  espe- 
cially galloping  and  trotting  on  a  wild  horse.  In  the  above- 
named  cases  of  pure  haemorrhoids,  the  bleeding,  while  it 
determined  the  disappearance  of  the  morbid  symptoms,  did  not 
in  the  very  least  weaken  the  patient,  neither  did  it  cause  any 
anaemia,  or  any  generally  bad  consequences ;  whereas  haemor- 
rhoidal bleeding  aggravated  by  the  abuse  of  alcohol  or  by  dis- 
eases of  the  rectum  or  anus  (as,  for  instance,  by  rupture  of  the 
dilated  veins),  may  cause  dangerous  anaemia  and  debility  of 
the  organism. 

I  will  turn  now  to  derivative  blood-letting.  It  stands  to 
reason  beyond  doubt,  that  the  observation  of  cases  in  which  the 
morbid  symptoms  m  the  head,  chest,  and  other  organs  disap- 
peared consequent  on  haemorrhoidal  bleeding  gave  rise  to  the 
idea  of  bloodletting  at  the  circumference  of  the  back  passage  for 
affections  of  the  head,  chest  etc.,  the  aim  in  view  being  not  de- 


—  399  — 

pletioii  alone ;  to  effect  depletion  onl}-,  it  would  be  much  more 
natural,  in  case.  say.  of  affections  of  the  head,  to  choose  as  a 
place  for  blood-extraction  one  much  less  distant  from  the  head. 
As  a  matter  of  fact,  bloodletting  from  the  circumference  of  the 
back  passage  has  since  long  been  considered  as  of  a  derivative 
nature.  It  is  certain  that  at  the  beginning  there  occurred  fre- 
quent mistakes,  when  haemorrhoidal  bloodletting  was  recom- 
mended for  such  affections  of  the  head,  chest,  and  other  organs, 
in  which  not  only  haemorrhoidal.  but  any  other  bloodletting 
was  contraindicated,  and  it  was  only  in  the  course  of  time  that 
experience  showed  where  the  former  was  suitable.  To  explain 
the  nature  of  observations  on  which  I  base  my  personal  opmion 
as  to  a  special,  not  only  a  depletive,  effect  of  blood-extraction 
from  the  circumference  of  the  back  passage,  I  will  cite  a  case 
in  my  practice  which  I  had  under  my  observation  twenty-five 
years  ago,  and  about  which  1  delivered  an  address  before  this 
society  in  October,  1864.  Although  I  have  had  many  occasions 
before  as  well  as  since,  to  see  cases  proving  without  doubt  a 
special  influence  and  value  of  haemorrhoidal  blood-extraction, 
and  pointing  to  indications  for  it.  still  this  observation  is  par- 
ticularly strong  in  its  conclusiveness. 

I  was  called  to  attend  a  woman  suffering  from  severe  nose- 
bleed :  she  lost  a  full  deep-bottomed  plate  of  blood,  and  the 
bleeding  still  continued  in  spite  of  all  the  adopted  measures. 
Patient  was  a  woman  of  about  forty  years  of  age,  of  very  ro- 
bust constitution,  living  in  favorable  conditions  of  life :  she  had 
until  recently  enjoyed  good  health,  and  at  the  time  presented 
nothing  abnormal,  outside  of  the  bleeding  and  some  trifling  gene- 
ral weakness  and  that  of  the  pulse  ;  everything  was  in  good  order ; 
there  was  only  a  feeling  of  heaviness  in  the  head  and  an  oppres- 
sive mental  state.  Inquiry  elicited  the  fact  that  some  time  ago, 
while  driving  in  a  sled,  the  patient's  feet  were  severely  chilled, 
but  on  her  return  home  they  became  warm  again  and  she  con- 
tinued to  feel  well ;  however,  the  menstrual  flow  which  followed 
soon  after  this  occurrence  and  which  was  formerly  regular  and 
abundant,  was  at  that  time  very  scanty  and  terminated  much 
sooner  than  at  the  usual  period.  By  the  end  of  the  menstru- 
ation patient  began  to  feel  heaviness  in  the  head,  and  in  a  few 
days  there  appeared  the  nose-bleed,  the  feeling  of  heaviness  not 
abating.  I  ordered  ice  on  the  head,  and  for  internal  adminis- 
tration infusum  secalis  cornuti  ex  3ij  ad  3vj ;  in  the  course  of  the 
day  and  night  the  bleeding  ceased  somewhat,  but  it  again  in- 
creased in  the  morning  and  she  lost  another  plateful  of  blood. 


—  400  — 

I  then  put  aside  the  ice  and  the  ergot  and  ordered  four  leeches 
to  the  circumference  of  the  back  passage.  By  the  time  the 
leeches  had  fallen  off  the  bleeding  ceased,  and  did  not  return 
again.  On  the  morning  of  the  next  day  the  heavmess  in  the 
head  disappeared,  tlie  patient  felt  as  usual  hale  and  strong ;  she 
did  not  even  complain  of  weakness ;  the  following  menstrual 
periods  were,  as  formerly,  regular  and  abundant. 

It  is  apparent  that  m  this  case  the  action  of  the  four  leeches 
applied  to  the  circumference  of  the  back  passage  consisted  in 
producing  a  depletion  of  the  circulatory  system  :  the  abundant 
depletion  through  the  nose  —  the  blood  filling  a  deep-bottomed 
plate  —  did  not  remove  the  sensation  of  heaviness,  nor  did  it 
avert  the  severe  haemorrhage  on  the  next  day ;  whereas  but  an 
insignificant  haemorrhoidal  blood-extraction  (as  the  four  leeches, 
together  with  the  bleeding  following  their  bites,  could  at  a  maxi- 
mum abstract  but  eight  ounces  of  blood)  stopped  the  haemor- 
rhage, relieved  the  head  symptoms,  and  all  this  so  rapidly  and 
so  decidedly,  that  to  ascribe  this  fact  to  accident  would  be  equiv- 
alent to  closing  one's  eyes  to  an  obvious  fact,  and  to  manifest- 
ing one's  incapacity  for  observation. 

If  the  effect  of  the  haemorrhoidal  bloodlettingf  in  the  de- 
scribed  case  was  not  of  a  depletive  nature,  what  was  it  then? 
I  call  this  effect  derivative.,  so  that  it  may  not  be  confounded 
with  depletion,  and  may  be  named  by  a  special  term ;  I  em- 
ploy for  this  purpose  the  term  derivative,  as  one  long  in 'use, 
but  I  do  not  connect  with  this  name,  for  the  sake  of  explaining 
the  nature  of  the  alluded  effect,  any  theory,  which  is  an  impos- 
sible thing  in  the  present  condition  of  our  science. 

I  will  note  here  another  thing.  In  the  above  described  case 
I  did  not  resort  to  tamponade  of  the  nasal  cavity,  and  the 
termination  of  the  case  has  completely  justified  my  mode  of 
action.  I  will  also  say,  that  there  occur  cases  of  nose-bleed,  in 
which  a  tamponade  of  the  nasal  cavity  may  become  directly 
dangerous  :  thus  I  had  occasion  to  see  patients  over  sixty  or 
seventy  j^ears  of  age  who  since  childhood  had  a  predisposition 
to  bleeding ;  this  last  is  usually  preceded  by  and  at  times  it 
relieves  cerebral  congestion.  There  occur  cases  in  which  such 
haemorrhages  become  excessive,  without  however  affording  any 
relief  to  the  symptoms  in  the  head :  in  such  I  consider  tampo- 
nade as  an  extremely  risky  procedure,  for  it  may  tend  to  cere- 
bral extravasation  of  blood,  and  I  resort  to  sliglit  haemorrhoidal 
blood-letting,  —  usually  with  the  same  success  as  in  the  above- 
described  case. 


—  401  — 

The  Indications  for  Derivative  Bloodletting. 

1.  In  the  region  of  the  head.  —  Cerebral  congestion,  without  a 
simultaneous  affection  of  the  circulatory  system,  and  also 
in  connection  with  diseases  of  the  heart  and  blood-vessels,  espe- 
cially in  those  cases  where  along  with  the  constantl}^  present 
phenomena  of  cerebral  congestion  (as  disturbed  sleep,  gloomy 
and  irritable  mental  state,  heaviness  m  the  head,  pain  in  the 
neck  and  at  times  in  the  temples,  reeling  during  walkmg, 
dizziness  on  stooping  down,  etc.)  there  occur  at  times  also  sud- 
den fluxes  of  blood  to  the  head  (the  face  flushes  rapidly  and 
deeply),  reminding  one  of  haemorrlioidal  molumina,  and  threaten- 
ing with  an  approaching  apoplectic  attack.  If  the  phenomena  of 
cerebral  congestion  are  of  moderate  severity  and  not  of  an  ur- 
gent character,  I  at  first  regulate  the  mode  of  living,  prescribe 
less  of  mental  work,  more  of  exercise,  walking,  and  massage  of 
the  feet  which  are  usually  cold  and  chilly  in  such  patients.  I 
regulate  the  diet,  remove  various  morbid  conditions  which  tend 
to  keep  up  the  cerebral  congestion,  such  as  constipation,  cough 
(usually  due  to  a  catarrhal  condition  of  the  larynx  or  the 
bronchi),  and  only  then  do  I  resort  to  the  derivative  bloodletting, 
when  the  above-named  measures  fail  to  produce  the  desired  ef- 
fect. But  if  the  phenomena  of  cerebral  congestion  be  strongly 
developed  and  the  patient  be  of  robust  constitution  with  good 
nutrition  and  good  haematopoiesis,  and  particularly  if  the  above- 
mentioned  influxes  occur,  then  I  at  once  apply  a  few  leeches  (in 
very  threatening  cases,  as  I  explained  above,  I  do  bloodletting), 
and  together  with  this  I  resort  to  the  above-enumerated  meas- 
ures. I  will  state  here  that  an  ice-bag  applied  in  such  cases  to 
the  head  exerts  but  a  trifling  effect  which  passes  as  soon  as  the 
bag  is  taken  off.  Of  the  stability  and  duration  of  the  effects  of 
the  derivative  bloodletting  in  the  above-named  affections  of  the 
head,  as  well  as  in  diseases  of  other  organs,  I  shall  speak  later 
on,  when  expounding  the  method  of  derivative  bloodlettmg  m 
connection  with  the  question  of  repeating  the  same. 

For  the  above-described  cases  of  cerebral  congestion  I  do  not 
resort  to  the  application  of  leeches  behind  the  ears  and  to  the 
nasal  septum,  i.  e.  with  a  direct  depletive  purpose.  We  can  apply 
but  a  few  leeches  to  the  nasal  septum  (two  to  four),  so  that  we 
are  unable  to  get  any  sufficient  effect :  and  according  to  some 
observations  we  are  led  to  think,  that  such  an  insufficient  deple- 
tion from  the  given  place  may  even  tend  to  increase  the  phenom- 
ena of  cerebral  congestion.  The  application  of  leeches  behind 
the  ears  may  certainly  relieve  the  attacks  of  cerebral  congestion ; 


_  402  — 

but  /first,  we  shall  be  compelled,  to  effect  this,  to  apply  at  least 
twice  as  may  leeches  as  we  would  do  for  the  derivative  (hae- 
morrhoidal)  bloodletting,  i.  e.  we  shall  find  it  necessary  to  cause 
twice  as  great  a  loss  of  blood,  and  secondly,  even  aftey.  such  a 
loss  of  blood  we  fail  to  obtain  as  complete,  stable  and  lasting  an 
effect,  as  we  do  with  the  derivative  bloodletting. 

There  is  only  one  class  of  cases  for  which  I  continue  to 
apply,  as  I  consider  it  an  undoubtedly  correct  and  valuable 
practice,  my  former  method  of  bloodletting  in  the  region  of  the 
head  with  a  direct  depletive  aim  in  view.  I  refer  to  the  appli- 
cation of  two  to  four  leeches  to  the  nasal  septum  in  cases  of 
cerebral  hj^eraemia  in  infectious  diseases,  most  frequently,  of 
course,  in  typhus  and  in  typhoid  fever.  There  occur  cases  of 
these  diseases,  in  which  during  several  days  there  continue 
symptoms  of  cerebral  congestion  very  distressing  to  the  patient, 
namely:  severe  headache,  insomnia,  at  times  violent  delirium, — 
all  these  accompan3"mg  a  distinctly  flushed  face;  then  there  oc- 
curs nasal  bleeding  and  the  symptoms  are  considerably  relieved 
(there  is  nsually  with  this  also  a  considerable  fall  in  the  tem- 
perature, which  continues  for  some  time),  without  however 
causmg  an}^  marked  weakness  in  the  patient.  If  in  such  cases 
the  bleeding  from  the  nose  does  not  occur  for  a  long  time,  while 
the  further  development  of  the  symptoms  and  their  deleterious 
effect  on  the  condition  of  the  patient  continue,  yielding  but 
slightly  to  ice  applications  to  the  head,  then  if  the  patient  be  at 
all  strong,  it  is  necessary  to  apply  two,  rarely  three  or  four 
leeches  to  the  nasal  septum  ;  bloodlettmg,  even  if  it  be  inconsider- 
able (and  this  is,  of  course,  desirable,  in  such  cases),  is  suffi- 
ciently effective  in  removing  the  above-mentioned  symptoms. 
The  application  of  leeches  to  the  circumference  of  the  back 
passage  in  such  patients  would  be  extremely  inconvenient ;  and 
besides  the  eft'ect  of  the  derivative  bleeding  in  these  cases  is 
uncertain. 

2.  In  the  region  offJie  apinal  coluvin.  —  Hyperoimia  of  the  spinal 
cord  mtd  of  its  membranes^  as  evidenced  by  pain  along  the  tract 
of  the  spinal  column  and  in  the  region  of  both  sciatic  nerves 
(the  trunks  of  the  last  presentmg  no  tenderness  on  pressure, 
thus  showing  the  absence  of  symptoms  of  neuritis),  occurring  in 
the  majority  of  cases  simultaneously  with  symptoms  of  cerebral 
congestion,  rarel}-  by  itself  or  to  a  more  predominating  extent. 
It  is  well  understood,  that  before  ordering  the  application  of 
leeches  we  must  by  a  careful  diagnosis  determine  exactly  the  na- 
ture of  the  affection,  so  as  not  to  confound  with  it  other  diseases 


—  403  — 

of  the  spinal  cord  and  its  membranes,  as  well  as  spinal  synovites 
neurites  and  mj^osites,  and  also  various  functional  nervous  dis- 
turbances, sucb  as  neurasthenia  and  hysteria,  and  abdominal 
diseases,  as  hepatic  and  renal  colics,  constipation,  etc.  With  a 
correct  diagnosis  on  hand,  the  effect  of  the  haemorrhoidal  blood- 
letting on  the  symptoms  of  hyperaemia  of  the  spine  and  its  mem- 
bers is  just  as  stable  and  complete,  as  it  is  in  cerebral  congestion. 
It  is  of  course  difficult  to  determine  as  to  how  much  of  this 
effect  is,  in  these  cases,  of  a  derivative  character,  and  how 
much  of  a  depletive  one  ;  be  as  it  may,  it  is  incomparably  more 
efficacious  than  bloodletting,  even  if  more  abundant,  but  pro- 
duced anywhere  higher  up  along  the  tract  of  the  spinal  cord. 

o.  In  the  region  of  the  chest.  —  (a)  In  haemoptysis  not  due  to 
any  organic  causes,  in  the  presence  of  healthy  lungs  and  heart. 
Such  haemoptysis,  as  is  well  known,  usually  occurs  in  young 
persons  predisposed  to  pulmonary  tuberculosis,  and  also  in  such 
young  persons,  who  are  not  predisposed  to  this  disease,  but  who 
have  a  weakened  nervous  system,  especially  as  a  result  of  sex- 
ual irregularities,  and  who  are  at  the  same  time  inclined  to  pure 
haemorrhoids,  i.  e.  haemorrhoids  under  which,  as  I  explained 
above,  we  understand  an  angioneurotic  condition.  If  a  hae- 
moptysis of  this  nature  does  not  rapidly  yield  to  other  meas- 
ures, then  the  most  reliable  means  is  slight  haemorrhoidal 
bloodletting.  This  will  of  course  bring  about  only  a  cessation 
of  the  haemoptysis  for  the  time  being  ;  later  on  the  repetition 
of  haemoptysis  must  be  met  with  by  radical  measures,  which 
consist  in  strengthening  the  organism,  in  removing  the  neuras- 
thenia and  the  sexual  irregularities,  etc. 

(b)  Haemoptysis  in  pulmonary  tubercniosis,  excepting  those 
cases  in  which  it  is  caused  by  destruction  of  large  blood-vessels 
in  cavernous  regions.  If  the  haemoptysis  be  at  all  considerable, 
without  yielding  quickly  to  other  measures  (among  other  things, 
in  the  presence  at  the  same  time  of  constipation  with  a  distend- 
ed abdomen,  which  is  not  relieved  by  a  laxative),  and  in  case 
the  patient  does  not  present  any  signs  of  great  weakness,  then 
I  order  two,  seldom  three  leeches  to  the  coccjrx,  and  I  must 
here  testify  to  the  successful  effect  of  such  bloodletting ;  the 
haemoptysis  ceases  without  causing  any  particularly  noticeable 
weakness  of  the  patient. 

(c.)  Haemop)tysis  in  diseases  of  the  heart.,  princip}ally  in  affec- 
tion of  the  left  venous  opening.  —  In  these  cases,  especially  if  at 
the  same  time  the  liver,  as  a  result  of  blood-stasis,  be  enlarged 
and  sensitive,  and  after  the  other  indications,  such  as  the  relief  of 


—  404  — 

constipation,  the  regulation  of  cardiac  activity,  etc.,  have  been 
fulfilled  without  bringmg  about  the  desired  results,  then  we 
must  resort  to  bloodlettmg.  I  will  recall  to  your  mind  what  1 
said  before  in  connection  with  bloodletting,  that  in  such  cases 
of  a  pronounced  disturbance  of  compensation  we  must  employ 
bloodletting,  even  before  fulfilling  the  other  indications  ;  in  case 
disturbances  of  compensation  be  absent,  and  the  moderate  hae- 
moptyses  recur  frequently,  without  yielding  to  other  treatment, 
then  we  must  apply  a  few  leeches  to  the  coccyx. 

4.  hi  the  ahdominal  region.  —  For  blood-stasis  in  the  liver  and 
consequently  in  cases  of  impeded  circulation  in  the  portal  sys- 
tem, as  caused  by  diseases  of  the  heart,  by  immoderate  eating 
and  by  the  use  of  alcoholic  drinks,  etc.  If  in  such  cases  of  enlarged 
and  sensitive  liver  there  predominate  biliary  disturbances  point- 
ing to  an  insufficient  secretion  of  bile  (as  a  bitter  taste,  at 
times  vomiting  of  bile,  an  insufficient  coloring  of  the  excreta ; 
symptoms  of  biliary  pigment  in  the  urine),  in  connection  with  a 
particular  tenderness  in  the  region  of  the  gall-bladder  and  with 
a  simultaneous  constipation,  then  it  is  advisable  to  give  calomel. 
But  if  the  enumerated  biliary  symptoms  are  absent,  then  there 
is  an  indication  for  the  application  of  leeches  to  the  coccyx.  It 
is  hard  to  determine  as  to  how  much  of  the  effect  of  the  leeches 
in  these  cases  is  of  a  derivative  nature  and  how  much  of  a 
depletive  one  ;  but  the  principal  thing  is  that  it  is  effective, 
incomparably  more  so,  with  a  smaller  number  of  leeches,  than 
the  effect  produced  by  applying  the  same  along  the  right  hy- 
pochondrium,  which  procedure  would  be  an  unpardonable  mis- 
take in  such  cases,  just  as  it  would  be  erroneous  in  pericystitis 
of  the  gall-bladder  to  apply  leeches  to  the  coccyx,  instead  of 
along  the  right  hypochondrium. 

5.  In  inflammation  of  large  haemorrhoidal  nodes,  leeches 
when  applied  to  the  coccyx,  acting  at  one  and  the  same  time 
both  as  a  depletive  and  as  a  derivative  measure,  serve  in  very  pro- 
nounced cases  as  the  most  effective  means. 

In  conclusion  let  me  say  here  a  few  words  regarding  the 
method  of  employing  derivative  bloodletting. 

As  any  other  blood-extraction,  it  must  be '•performed  in  the 
presence  of  the  physician,  and  especially  so  in  the  above-named 
cerebral  and  chest  cases.  In  other  cases,  in  patients  who  are 
not  weak,  we  may  rely  on  a  male  or  female  assistant-surgeon 
(Feldscher)  if  they  are  well  known  to  the  physician,  reliable, 
familiar  with  the  alteration  of  the  pulse,  and  are  able,  when 


—  405  — 

necessary,  to  administer  stimulants,  as  Valeriana  or  Hoffman's 
drops,  which  may  at  times  become  necessary  for  patients  with 
a  weakened  nervous  system,  or  in  those  who  have  become 
frightened  even  before  the  leeches  are  applied.  I  will  state 
here  that  a  weak  pulse  does  not  always  constitute  a  contraindi- 
cation for  derivative  bloodletting,  as  was  partly  also  explained 
in  connection  with  the  subject  of  the  more  considerable  blood- 
letting —  venesection.  Bloodletting  should  be  performed  in  as 
spacious  and  airy  a  room  as  possible. 

The  time  of  the  day,  —  The  best  is  during  the  evening,  before 
going  to  bed,  so  that  after  the  application  of  the  leeches  the 
patient  may  remain  m  bed  until  morning  ;  however,  in  urgent 
cases  it  may  be  done  at  any  time. 

No  leeches  are  to  be  applied  immediately  after  taking  food, 
but  some  time  later  in  accord  with  the  quantity  of  the  same. 
The  intestinal  tract  should  be  evacuated  as  a  preliminary  meas- 
ure :  if  this  be  sufficiently  effected  by  an  injection,  then  it 
should  be  made  directly  before  the  leeches  are  applied  ;  but  if 
there  is  a  necessity  for  the  employment  of  a  laxative,  then,  hav- 
ing administered  this  last,  we  must  of  course  wait  for  its  effects 
and  then  wait  for  a  few  hours  before  we  apply  the  leeches,  and 
before  doing  this  we  administer  some  stimulant  so  as  to  avoid 
any  weakening  on  the  part  of  the  patient. 

The  position,  of  the  fatient  must  be  lying,  or  at  least  reclining 
(in  dyspnea)  on  the  side.  The  practice  formerly  in  vogue  of 
performing  haemorrhoidal  bloodletting  with  the  patient  in  a 
sitting  posture  may  tend  to  call  out  dangerous  fainting. 

The  site  of  the  derivative  bloodletting  is,  as  explained  above, 
pointed  out  by  nature  itself,  namely,  the  circumference  of  the 
back  passage ;  but  I  order  leeches  to  the  coccyx,  and  not  all 
over  the  circumference  of  the  anus  :  for  this  last  is  much  more 
painful  and  serves  later  as  an  obstacle  to  defecation ;  it  is  more- 
over more  difficult  to  stop  the  bleeding  in  this  locality  and  to 
preserve  the  necessary  cleanliness. 

The  day  following  the  bloodletting  the  patient  should  remain 
at  home,  so  that  the  wounds  caused  by  the  leeches  may  heal  the 
sooner,  and  in  case  he  feels  any  weakness  —  which,  if  the  indica- 
tion be  correctly  understood  and  the  number  of  leeches  carefully 
considered,  will  occur  but  very  rarely,  and  even  then  during 
the  first  day  only  —  then  he  should  take  two  or  three  doses  of 
the  above-named  stimulant  drops. 

The  number  of  leeches.  —  During  my  early  practice  I  had  fre- 
quent occasions  to  see  usually  ten  leeches  applied,  seldom  less. 


—  406  — 

more  frequently  a  greater  number,  as  twelve  to  fifteen,  at  times 
twenty  and  even  more.  I  was  then  convinced  of  the  undoubted 
harm  of  such  considerable  extraction  of  blood,  and  I  began 
to  apply  five  leeches,  thinking  that  in  case  of  necessity  I  can 
repeat  the  bloodletting.  Experience  has  taught  me  that  there  are 
but  very  rare  cases  where  we  have  to  repeat,  i.  e.  to  apply  twice 
five  leeches,  in  the  course  of  a  few  days  :  in  the  majority  of  cases 
five,  in  exceptional  cases  six  or  seven  leeches,  produce  a  suffi- 
cient effect.  The  number  of  five  (or  six  to  seven)  refers  to  all 
the  above-enumerated  indications,  with  the  exception  of  the 
chest  indication — the  haemoptyses  :  for  these  I  never  use  more 
than  five,  more  often  four  or  three,  and  in  pulmonary  tuber- 
culosis, as  alluded  to  above,  even  two. 

To  keep  up  the  bleeding  after  the  leeches  fall  off.  —  Experience 
has  proved  that  derivative  bloodletting  is  attended  with  the 
best  effects  when,  after  the  leeches  fall  off,  the  bleeding  is  kept 
up  by  washing  the  wounds  with  warm  water  until  the  blood,  at 
the  beginning  usually  very  dark,  becomes  bright  red  in  color. 

The  repetition  of  derivative  bloodletting.  —  Among  the  ob- 
jections against  this  last,  —  raised,  however,  usually  by  persons 
who  do  not  themselves  resort  to  it,  and  thus  lack  the  necessary 
experience,  —  we  hear  this  one,  that  derivative  bloodletting  once 
produced  determines  by  this  fact  alone  the  necessity  for  its  being- 
repeated.  From  long  experience  I  will  state  the  following :  if, 
for  instance,  cerebral  congestion  (and  this  may  be  said  of  the 
other  indications  for  derivative  bleeding)  was  relieved  at  the 
given  time  by  the  application  of  leeches  to  the  coccyx,  if  with 
this  the  causes  producing  the  cerebral  congestion  were  removed, 
and  the  patient  follows  strictly  the  physician's  advice  which 
will  result  is  setting  aside  these  causes,  then  there  is  usually  no 
necessity  for  a  repetition  of  the  derivative  bleeding.  But  if 
the  patient  neglects  the  physician's  instructions,  and  conse- 
quently thus  permits  the  causes  of  the  congestion  to  further  exert 
their  deleterious  mfluence,  or  if  these  causes  be  not  removable, 
then  certainly,  to  avoid  the  worst  consequences,  we  are  com- 
pelled to  repeat  the  application  of  the  leeches  once  or  twice 
during  the  year,  —  rarely,  in  very  exceptional  cases,  more  fre- 
quently, usually  in  the  course  of  time,  in  a  smaller  number 
than  at  the  beginning ;  but  if  the  number  of  leeches  is  ordered 
with  care,  in  accord  with  the  patient's  idiosyncrasies,  his  con- 
stitution, haematopoietic  ability,  and  so  on,  then  we  never 
observe  any  anaemia,  nor  any  weakening  of  the  patient  result- 
ing from  derivative  bloodletting. 


CALOMEL. 


IN  HYPERTROPHIC  CIRRHOSIS  OF  THE  LIVER  AND 
IN  GENERAL  THERAPY.* 

The  principal  mercurial  compound  used  in  the  treatment  of 
internal  diseases,  outside  of  syphilis,  is  certainly  calomel.  As 
is  well  known,  there  exist  various  views  regardmg  its  effective- 
ness. In  England  calomel  is  highly  valued  and  is  one  of  the 
ordinary,  commonly  used  drugs,  although  less  so  than  it  was  at 
the  beginning  of  the  present  century,  when  it  became  known. 
In  France  it  is  not  so  much  valued  and  its  employment  is 
limited  ;  but  in  a  general  way  there  is  a  considerable  similitude 
in  its  use  with  the  English  practice.  But  it  is  quite  different  in 
Germany.  According  to  Nothnagel  and  Ross  bach  there  is  to 
be  noted  a  progressive  scepticism  in  the  direction  of  internal 
mercurial  treatment  (except  in  syphilis),  so  that  at  the  present 
time  there  is  hardly  one  positive  indication  for  the  use  of  the 
drug.  The  above-named  authors  consider  calomel  as  a  conven- 
ient laxative  at  times.  As  far  as  I  am  acquainted,  from  liter- 
ature and  personal  experience,  with  the  modern  practice  of  the 
German  physicians  and  their  attitude  toward  calomel,  I  can  but 
substantiate  the  correctness  of  the  authors'  statement.  It  how- 
ever occurs  to  me  that  calomel  is  not  fully  appreciated  by  the 
modern  German  practitioners  in  its  application  to  the  treatment  of 
diseases  of  the  liver,  namely,  of  the  biliary  tract.  Thus,  even 
the  work  of  Binz  (  *•  Arzneimittellehre  "  ),  the  tendency  of  which 
can  hurdly  be  called  sceptical,  contains  no  such  indication  for  the 
employment  of  this  drug.  The  tendency  of  the  Russian 
practice  is  similar  to  what  we  find  among  the  Germans,  name- 
ly, the  same  progressive  scepticism  that  began  in  the  fifties  ;  the 
condition  at  present,  as  far  as  I  am  aware,  is  the  same  as  in 
Germany,  I  do  not  speak  of  myself  and  those  of  my  former 
students  who  had  the  opportunity  to  see  me  use  calomel  in  the 
clinic. 

*  Address  delivered  before  the  Moscow  Physio-Medical  Society,  Jan- 
uary, 1884. 

407 


—  408  — 

During  the  fifties,  when  I  was  a  student,  and  later  on  as  an 
.assistant  in  the  clinic,  I  had  frequent  opportunities  to  observe 
the  use  of  calomel.  I  failed  to  see  an}^  successful  results,  but 
saw  a  great  deal  of  harm  done.  The  causes  of  this  were  to 
be  found  in  the  poor  diagnostication  of  those  times,  in  the 
insufficient  exactness  of  the  indications  for  the  use  of  the 
remedy,  namelj-,  in  what  diseases  it  should  be  used,  when 
to  begin  and  when  to  stop  its  administration  (failure  to 
properly  indicate  all  this  led  to  unnecessary  diarrhoeas  and 
exhaustion  of  the  patient)  ;  then  in  the  inability  to  prevent  the 
occurrence  of  stomatitis,  as  the  use  of  potassium  chlorate  as 
a  gargle  was  unknown  then.  But  at  the  same  time  I  happened 
to  observe  once  a  case  outside  of  the  clinic,  where  an  old 
physician,  without  making  a  diagnosis,  but  simplj'  on  account 
of  the  presence  of  the  "status  biliosus,"  administered  calomel 
in  a  small,  slightly  laxative,  dose ;  the  immediate  marvellous 
improvement  in  the  patient's  condition  has  impressed  itself 
upon  my  memory.  Since  1860  I  conducted  an  mde^^endent 
clinical  and  private  practice,  at  the  beginning  of  which,  under 
the  influence  of  the  general  ''■  progressive  scepticism "'  toward 
calomel,  I  almost  never  used  it ;  but  some  four  years  later  I  had 
to  resort  to  it,  and  since  that  time  I  have  learned  to  appreciate 
the  value  of  this  remedy.  In  the  following  lines  1  intend  to 
bring  forward  proofs  of  my  conviction,  that  calomel  in  diseases 
of  the  biliar}^  passages  is  a  valuable  drug  which,  in  the  present 
condition  of  therapy,  cannot  be  replaced.  In  connection  with 
this  I  will  also  touch,  in  a  few  lines,  on  the  use  of  calomel  in 
erysipelas,  typhoid  fever,  pneumonia,  and  acute  B right's. 

I  must  touch,  in  a  few  words,  on  what  pharmacology  calls 
the  phj^siological  action  of  the  drug,  namely,  the  influence  of 
calomel  on  the  liver,  on  the  secretion  and  excretion  of  bile. 
The  development  of  scepticism  toward  calomel,  outside  of  the 
above-named  clinical  causes,  was  undoubtedly  aided  by  the 
fact,  that  whereas  the  phj^sicians  have  derived  the  greatest  good 
from  the  use  of  calomel  in  diseases  of  the  liver,  and  in  view  of 
the  well-known  dark-greenish  evacuations  following  its  use 
have  put  it  down  as  a  cholagogue,  pharmacological  investi- 
gations, by  the  aid  of  artificial  biliary  concretions,  have  led 
to  the  conclusion  that  not  only  is  the  quantity  of  secreted  bile 
not  increased  by  calomel,  but  on  the  contrary,  after  a  continuous 
use  of  the  same,  it  —  the  secretion — tends  to  diminish.  But  the 
doubtful  conclusions  of  these  pharmacological  data  as  regards 
the  calomel  therapy    in  diseases  of   the  liver  are,  to    say  the 


—  409  — 

least,  premature.  It  was  firstly  proved  that  the  dark-greenish 
color  of  the  usually  so  abundant  calomel  evacuations  is  due 
to  a  rapid  descent  of  bile  from  the  superior  portion  of  the 
intestine,  this  descent  being  caused  by  the  employment  of 
calomel  (but  of  no  other  laxative).  Further,  let  us  take  the 
following  from  the  above-mentioned  work  of  Binz :  "  If,  in 
accord  with  the  investigations  of  Shiff,  we  consider  that  the 
liver  not  only  prepares,  but  also  excretes  the  bile  already  pre- 
pared and  again  absorbed  by  the  intestines,  then  the  diminution 
of  the  latter  after  a  calomel  diarrhcea  becomes  clear " ;  and 
again :  "•  In  this  manner  calomel  frees  the  juices  of  a  possible 
superfluity  of  any  component  parts  of  the  bile,  and  can  be 
called  a  cholagogue  from  a  point  of  view  totally  different  from 
the  former."  We  will  add  that  Shiff's  theory,  on  which  the 
physiologists,  thanks  to  the  contradictory  results  of  Sokoloff's 
work,  looked  with  distrust,  has  received  lately  considerable 
support,  if  not  complete  confirmation.  Weiss  has  repeated 
Sokoloff's  experiments  in  the  laboratory  of  Prof.  Boulyginsky, 
and  after  three  years  of  labor  has  arrived  at  conclusions  con- 
tradicting those  of  Sokoloff,  but  substantiating  Shiff's  theory.* 
And  if  this  theory  be  correct,  then  we  may  assume  that  calo- 
mel, by  causing  a  considerable  excretion  of  bile  and  thus 
diminishing  its  absorption  and  its  return  to  the  liver,  cannot 
but  influence  also  the  formation  of  bile  in  the  liver,  as  accord- 
ing to  Shiif 's  theory  the  quantity  of  bile  secreted  by  the  liver 
is  made  up  of  that  which  was  reabsorbed  and  of  that  which 
was  newly  formed.  However  I  do  not  at  all  intend  to  enter 
upon  useless  hypotheses.  I  only  desired  to  show  that  the 
present  condition  of  the  pharmacological  data  can  in  no  man- 
ner serve  as  a  basis,  as  they  sometimes  did  and  do  now,  for  the 
sceptical  view  as  to  the  effectiveness  of  calomel  therapy  in 
hepatic  diseases.  I  again  repeat,  I  do  not  intend  to  elucidate 
the  pharmacology  of  calomel,  but  to  bring  forward  clinical  tes- 
timony as  to  the  effectiveness  of  this  remedy,  —  rather  to  deter- 
mine the  diseases,  in  which  its  use  is  successful,  and  to  clearly 
point  out  the  indication  for  it  in  the  sphere  of  such  diseases. 
The  English  practice,  to  which  calomel  owes  its  reputation, 
has  among  other  thmgs  given  a  very  indefinite  indication  for 
the  use  of  calomel,  namely,  torpor  of  the  liver,  an  indication,  by 
the  way,  that  remains  even  up  to  the  present  time  almost  the' 
most  frequent  one.  The  following  combination  of  symptoms 
is  embraced  under  this  designation :  constipation  or  a  general 

*  Vide  The  Physiology  of  Bile.     Moscow,  1883. 


—  410  — 

irregularity  of  the  intestinal  functions,  insufficient  coloring  of 
the  excreta,  a  too  great  development  of  the  intestinal  gases, 
a  pale,  sad  face,  low  spirits,  etc.  Such  a  picture  of  disease  may 
undoubtedly  be  seen  in  diseases  of  the  liver,  in  which  neither 
calomel  nor  anything  else,  m  the  present  state  of  therapy,  will 
be  of  any  avail,  as  for  instance  m  cancer,  in  multilocular 
echinococcus,  m  simple  (Laennec,  non  hypertrophic)  cirrhosis  of 
the  liver.  Again  this  picture  may  also  be  observed  in  other 
diseases  of  the  liver,  as  in  hj-peraemic  conditions  of  that  organ, 
in  which  calomel  may  be  effective,  but  m  which  other  drugs 
will  do  the  same  and  better,  and  must  be  for  certain  reasons 
preferred,  as,  for  instance,  mmeral  waters  containmg  Glauber's 
salt  (Marienbad).  My  investigations  lead  me  to  thhik  that  there 
are  only  two  diseases  of  the  liver,  or  properly  speaking,  of  the 
biliary  passages,  in  which  calomel  is  not  only  efficient,  but  will 
do  what  no  other  remedy,  in  thr;  present  condition  of  therapy, 
will,  be  it  a  laxative  or  otherwise. 

These  diseases  are :  severe,  especially  febrile  cases  of  colic 
from  biliary  calculi  fcolica  hepatica),  and  hypertrophic  cirrhosis 
of  the  liver. 

Severe,  especially  febrile  cases  of  colic  from  biliary  calculi. 
—  During  the  tirst  four  3'ears  of  my  practice,  as  I  said  before. 
I  never  used  calomel.  Ijut  some  twenty  years  ago  I  took  it  up. 
Here  is  the  first  case  which  induced  me  to  employ  it.  I  will 
relate  it  Imelly.  as  I  have  had  since  many  more  typical  cases 
and  had  the  opportunity  of  better  observation  (1  will  com- 
municate one  of  them  later  in  extensoj. 

Patient  was  about  fifty  years  old,  of  good  constitution,  lived 
in  favorable  circumstances  and  led  quite  a  regular  mode  of 
living ;  but  he  was  at  times  careless  with  his  food  and  also 
with  the  use  of  alcoholic  drinks.  CUiest  and  nervous  sys- 
tem normal.  Urine  reddish  in  color  (no  albumen).  There  were 
some  slight  gouty  phenomena  in  the  small  joints.  He  was 
troubled  with  dyspepsia  (there  was  no  evidence  of  any  gastric 
catarrh),  had  a  tendency  to  constipation,  slight  attacks  of  liver 
colic,  and  moderate  tenderness  on  pressure  m  the  region  of  the 
gall-l)ladder.  Fever  absent :  condition  of  strength  good.  I 
regulated  his  mode  of  living,  especially  the  diet,  and  pre- 
scribed Vichy  (C'elestins)  in  the  morning  on  an  empty  stomach, 
thi'ee  doses  aa  3V,  at  the  temperature  of  freshly  drawn  milk, 
and  at  times,  in  case  of  an  insufficient  emptying  of  the  intes- 
tines, the  third  dose  of  Vichy  ^va.s  replaced  by  a  similar  dose  of 
bitter    Friedrichshall    water,    also    warmed    somewhat.     There 


—  411  — 

followed  rapid  improvement  during  the  first  two  weeks :  ap- 
petite, sleep  and  mental  condition  became  better,  the  dyspeptic 
phenomena  and  the  pains  in  the  region  of  the  liver  disap- 
peared ;  less  tendency  to  constipation. 

Then,  after  this,  a  considerable  error  in  diet,  and  a  cold  at 
the  same  time  ;  the  patient  called  on  me  in  five  days,  complain- 
ing that  everything  became  worse,  although  he  continued  the- 
former  treatment.  To  be  sure,  the  appetite  was  gone;  the  pain 
in  the  region  of  the  liver  grew  much  sharper  and  was  aggra- 
vated after  drinking  the  mineral  waters,  especiall}'  the  bitter 
ones ;  there  appeared  slight  icteric  symptoms  and  obstinate  con- 
stipation. I  stopped  the  mmeral  water  and  administered  castor 
oil ;  he  vomited  up  the  first  teaspoonful,  but  had  a  stool  after 
the  second ;  but  his  condition  was  not  ameliorated.  There  ap- 
peared febrile  condition  with  an  evening  exacerbation.  I  gave 
him  three  three-grain  doses  of  quinine  in  the  course  of  the  day. 
He  grew  worse  by  the  next  day  :  pains  and  icteric  symptoms 
aggravated,  temperature  higher,  the  patient  is  weaker  and  more 
irritable.  I  then  administered  twelve  powders  of  calomel  grain 
j  (-f-  five  grains  of  sugar)  every  hour,  and  at  the  same  time  a 
gargle  of  potassium  chlorate  ;  verily,  tlie  effect  was  magical :  the 
patient  had  abundant,  characteristic  calomel  evacuations,  both 
the  fever  and  the  pains  disappeared  on  the  next  day,  the  sleep 
and  the  mental  condition  became  normal,  the  appetite  reap- 
peared. Two  days  later,  the  patient  returned  to  his  former 
treatment  with  the  mineral  water,  and,  punished  by  experience, 
kept  a  strict  diet,  and  soon  improved  completely. 

I  will  now  communicate  to  you  a  very  typical  case,  the  last 
of  a  similar  class  of  cases  seen  by  me,  and  one  of  those  that  I 
had  a  good  opportunity  to  observe :  the  patient  was  in  my  clinic 
last  summer  and  had  more  than  once  served  as  a  subject  of  my 
clinical  lectures  before  students  and  physicians. 

Mr.  N.,  a  member  of  the  circuit  court,  forty-two  years  of  age, 
entered  the  clinic  January  25,  1884,  complaining  of  severe 
pains  in  the  region  of  the  stomach,  under  the  right  hypochon- 
drium  and  all  over  the  abdomen,  of  jaundice,  feverishness,  and 
extreme  debility. 

Mode  of  life  and  anamnesis.  —  Patient  is  married,  has  no  syphi- 
lis, almost  never  used  any  alcoholic  drinks  formerly,  while 
during  the  last  year  and  a  half  drank  none  at  all.  The 
principal  irregularities  in  his  mode  of  living  were  as  follows: 
insufficient  sleep  (some  six  hours  in  the  twenty-four),  a  great 
amount  of  mental  labor  (fourteen  hours  a  day),  little  exercise 


—  412  — 

out  of  doors,  summer  in  the  city ;  smoked  about  fifty  cigarettes 
daily ;  had  irregular  meals  —  but  once  a  day  —  and  was  careless 
in  selecting  his  food.  The  last  year  and  a  half  the  patient 
was  compelled  by  poor  health  to  work  less  (three  hours  a  day), 
gave  up  smoking,  and  is  very  careful  with  his  diet ;  drinks 
tea  and  coffee  moderately,  without  cream  or  milk,  and  with  but 
a  small  quantity  of  sugar  (formerly  he  used  about  three-fourths 
of  a  pound  of  sugar  in  twenty-four  hours).  Ten  years  ago 
there  appeared  the  first  symptoms  of  neurasthenia :  low  spirits, 
quick  fatigue  from  mental  and  physical  labor,  constipation,  al- 
though the  gastric  digestion  was  satisfactorj.  The  patient 
took  silver  nitrate,  somewhat  improved  for  a  time,  but  continued 
to  work  hard,  slept  and  rested  little,  and  the  neurasthenic 
symptoms  became  more  and  more  aggravated  each  year.  The 
constipation  particularly  increased  the  last  four  years  and  the  pa- 
tient resorted  to  clysters  and  at  times  to  castor  oil.  During 
June,  1882,  he  had  the  first  attack  of  liver  colic;  in  October,  the 
second.  The  patient  drank  Vichy  and  Ems  for  a  week  and 
a  half  each.  In  November  another  attack  of  colic  with  nau- 
sea ;  again  Vichy  and  Ems  for  three  weeks.  In  April,  1883, 
another  attack  of  colic,  and  Vichy  and  Ems  for  three  weeks,  and 
from  the  latter  half  of  July  until  the  end  of  August  (for  about 
ten  weeks)  Karlsbad,  three  glasses  per  day.  September  30th 
and  October  1st,  while  riding  for  a  long  time  in  a  jolting  carriage, 
he  experienced  a  severe  attack  of  colic,  for  the  first  time  accom- 
panied by  jaundice  and  fever  (chills  and  later  heat).  Since 
then  and  up  to  the  time  he  entered  the  clinic  his  condition  was 
as  follows  :  every  day,  some  two  hours  after  dinner,  he  expe- 
riences a  painful  sensation  in  the  region  of  the  stomach  and  in 
the  right  hypochondrium.  The  pain  is  usually  of  moderate  se- 
verity and  lasts  for  about  one  hour ;  but  once  during  the  week 
it  is  quite  severe,  lasting  for  several  hours,  and  is  accompanied 
b}^  an  increase  m  the  jaundice ;  and  once  in  about  every  two  weeks 
(of  late  more  frequently)  there  appear  attacks  of  severe  colic 
lasting  three  to  four  days,  with  pronounced  jaundice  and  fever 
(40°),  which  begins  with  a  severe  chill  and  lasts  during  the 
three  or  four  days.  The  treatment  for  this  time  was  as  follows  : 
he  drank  continuously  first  Vichy,  later  Ems  in  small  doses  (f  v 
three  times  a  day),  and  used  laxatives  constantly :  either  an  ad- 
ditional teaspoon  of  Karlsbad  salt  to  the  mineral  water,  or  a  tea- 
spoonful  of  powdered  rhubarb  in  a  glass  of  water,  and  at  times 
castor  oil.  During  the  attacks  of  colic  accompanied  by  fever 
he  was  given  quinine  until  he  experienced  slight  buzzing  in  the 


—  413  — 

ears,  but  this  failed  to  produce  any  effect  on  the  fever.  The 
result  of  the  treatment  unsatisfactory :  the  attacks  of  colic 
and  fever  continued  to  increase  and  became  more  frequent ; 
there  appeared  intestinal  pains,  which  became  frequent  and 
more  severe  on  the  continuous  use  of  the  mineral  waters ;  the 
patient  became  very  emaciated,  debilitated,  lost  his  sleep  and 
was  in  bad  spirits. 

Status  January  2Jf^  ISSJj..  —  Patient  of  medium  constitution, 
and,  as  mentioned  above,  emaciated  and  weak.  Thqre  is  a 
moderate  jaundice  of  the  skin  and  of  the  sclerotics.  He  has 
almost  no  appetite,  some  thirst.  Has  belching  after  dinner,  and 
at  first  heaviness  in  the  stomach,  later  pains,  as  described  in 
the  anamnesis  ;  with  this  there  is  nausea,  and  at  times  vomiting, 
after  which  the  pains  grow  less  severe  for  some  time.  Abdo- 
men somewhat  distended ;  moderate  pressure  elicits  pain  in  the 
stomach,  and  much  more  of  it  in  the  region  of  the  gall-bladder ; 
liver  and  spleen  not  enlarged.  Notwithstanding  the  constant 
use  of  laxatives,  a  stool  takes  place  only  after  a  clyster  of 
warm  water  (and  even  then  not  always  satisfactorj^)  every 
other  day;  only  castor  oil  can  replace  the  clyster.  The  evacua- 
tions are  paler  than  normal,  pale  yellow.  Besides  the  attacks 
of  liver  colic,  i.  e.  of  pains  which  appear  two  hours  after  a 
meal,  in  the  stomach  and  under  the  right  hypochondrium, 
accompanied  at  times  by  nausea,  the  patient  is  suffering  from 
other  pains,  evidently  of  intestinal  origin,  in  the  umbilical 
region  and  along  the  course  of  the  large  intestine,  accompanied 
by  gurgling  and  relieved  after  an  emission  of  gases  or  after  a 
clyster.  The  urine,  500  c.  c.  in  twenty-four  hours,  is  red,  con- 
tains biliary  pigment,  but  neither  albumen,  nor  sugar.  Chest 
healthy.  Pulse  80-90,  very  weak.  Poor  sleep,  on  accomit  of 
abdominal  pains.  Mental  work  causes  headache.  Lately  fatigue 
brings  on  dizziness,  during  which  the  patient  grows  pale. 
Oppressed  low  spirits.  Patient  was  admitted  on  the  third 
day  of  his  usually  severe  attack  of  colic  with  fever.  Tempera- 
ture in  the  evening  38.6°  R.  (101.5°  _F.)  ;  in  the  morning  of  the 
next  day  38°  B.  (100.4°i^.),  evenmg  38.8°  B.  (101.8°i^.).  He  is 
lodged  in  a  dry,  warm  room,  and  ordered  at  first  to  be  confined 
there,  not  to  sit  for  a  long  time,  to  lie  down  at  once  on  feeling 
fatigued,  not  to  tire  himself  with  reading,  and  to  keep  the 
abdomen  warm  (Provence  oil  and  a  double  layer  of  flannel). 
Diet :  weak,  warm  tea,  without  milk  or  sugar ;  between  two  or 
three  tablespoonfuls  of  port  wine  per  day;  chicken  soup, 
chicken  meat  and  some  white  bread ;  he  is  to  eat  several  times 


—  414      - 

per  day,  but  never  to  satiety.  When  feeling  weak  and  dizzy, 
he,  is  given  twenty-five  drops  of  Trae.  Amnion.  Valer.  and  Liq. 
Anodyni  Hoffmanni  aa,  twice  or  three  times  a  day.  If  neces- 
sary a  clyster  of  warm  water  is  administered. 

January  27tli.  —  In  the  begmning  calomel  (one  grain  +  live 
grains  of  sugar)  every  hour,  and  after  the  fourth  dose 
ever}-  two  hours ;  from  this  day  on  constantly  gargling  his 
mouth  with  potassium  chlorate  (3ij  to  o^j).  After  the  seventh 
grain,  the  patient  had  a  thorough  clearing  of  the  bowels  with 
characteristic  calomel  evacuations,  without  intestinal  pains ; 
the  calomel  was  stopped  at  once. 

January  29th.  —  Morning  temperature  37°  R.  (98.6°  F.)^ 
evenmg  37.2°  R.  (99°  F.)  Patient  is  much  better :  he  has 
some  appetite,  almost  no  colic,  intestinal  pains  less  severe  and 
less  frequent;  amount  of  urine  1000  c.  c,  color  paler:  sleeps 
well,  feels  generally  better  and  stronger. 

February  1st.  —  Condition  same,  but  colic  somewhat  more 
severe ;  stool  onlj^  after  a  clyster ;  had  five  grains  of  calomel 
in  the  manner  as  above;  two  hours  after  the  last  dose,  the 
interne,  fearing  to  weaken  the  patient  more  with  a  superfluous 
dose  of  calomel,  ordered  a  spoonful  of  castor  oil.  Then  fol- 
lowed evacuations  as  formerly  and  also  a  similar  improvement. 

February  9th  and  10th.  —  Patient  has  no  fever,  feels  stronger 
and  heartier,  eats  better;  but  the  colic  has  been  worse  these 
days  ;  eight  grains  of  calomel  in  the  former  manner. 

February  11th.  —  No  stool.  Temperature  39.2°  R.  (102.5°  F.). 
Had  a  spoonful  of  castor  oil  (this  was  the  last  dose ;  he  was 
given  no  more  of  it).     A  good  calomel  evacuation. 

February  12th.  —  ^iovnmg  temperature  36.8°  R.  (98.2°  F.). 
evening  37.2°  R.  (99°  F.~)  ;  urine  1500  c.  c.  of  almost  normal 
color ;  colic  again  insignificant,  improvement  in  everything  else. 
Thus  up  to  February  17th. 

February  17th.  —  An  evident  error  in  diet ;  ate  too  much. 
Colic  much  stronger. 

February  18th.  —  A  severe  chill.  Temperature  in  the  morn- 
ing 40.1°  R.  (104.1°  i^.).  Was  given  calomel,  one  grain  every 
hour.  He  had  a  stool  after  the  fourth  dose.  a,nd  did  not  get 
any  more.     Evening  temperature  37,6°  R.  (99.6°  i^.). 

February  19th.  —  Mornmg  temperature  37°  R.  (98.6°  F.~), 
evening  39.2°  R.  (102.5°  F.^.  Xo  further  laxation.  Was 
given  six  grains  of  calomel,  as  before. 

February  20th.  —  A  good  calomel  stool.  Mornmg  tempera- 
ture 36.9°  R.  (98.2°  ^.),  evening  37.1°  R.  (98.8°  F.)  No 
colic. 


—  415  — 

From  this  day  on  the  patient's  condition  continued  improv- 
ing :  the  fever  disappeared,  the  patient  ate  more  and  digested 
well  (no  heaviness  and  belching)  ;  the  clyster  acted  better, 
and  at  times  the  bowels  moved  without  any  clyster;  the 
intestinal  pains  appeared  at  rarer  intervals,  and  were  much 
less  severe  than  formerly  ;  the  color  of  the  urine  became 
normal  and  the  general  jaundice  began  to  disappear ;  he  began 
to  sleep  better,  has  grown  stouter  and  stronger.  The  attacks 
of  liver  colic  appeared  now  and  then,  but  each  time  they  grew 
weaker  and  weaker.  At  such  times  he  was  always  given  calo- 
mel :  February  29th,  March  3d,  9th.  15th,  eight  grains  on 
each  day,  and  the  last  time,  March  24th,  four  grains,  with  good 
effects,  without  ever  causing  any  laxative  action. 

Since  March  24th  he  had  no  attacks  of  liver  colic,  the 
sensitiveness  in  the  region  of  the  stomach  and  gall-bladder  dis- 
appeared even  before,  and  a  little  later  the  intestinal  pains  also 
ceased.  The  patient  began  the  use  "of  condurango  since  April 
1st,  3SS.  in  fvj,  two  tablespoonfuls  per  day.  He  left  our  clinic 
April  21st  entirely  improved ;  the  appetite  and  digestion  be- 
came normal,  he  had  stools  without  the  aid  of  clysters,  and  all 
the  abdominal  pains  disappeared :  he  has  grown  somewhat 
stouter,  quite  strong  and  hearty.  Since  the  latter  half  of 
February  he  had  warm  baths  twice  a  week :  at  first  at  30°  R.  — 
as  he  was  quite  chilly — six  baths;  and  before  leaving,  when 
with  the  improvement  in  sleep,  he  became  less  chilly,  tliree 
baths  at  28°,  27.5°  and  27°  R,  The  baths  at  30°  R.  quieted 
the  patient,  while  cool  ones  strengthened  him.  , 

Twenty  years  passed  in  the  interval  between  these  two  cases 
the  first  and  the  last.  During  this  period  I  had  the  opportunity 
of  observing  many  such  patients,  and  of  employing  calomel. 
With  all  their  various  peculiarities  these  cases  all  present,  in 
their  principal  traits,  the  same  characters  as  the  two  related 
above.  My  practice  is  as  follows  :  the  simplest  cases  of  liver 
colic  accompanied  by  some  dyspeptic  phenomena  require  only  a 
strict  diet  and  a  generally  regulated  mode  of  living ;  but  such 
oases  are  certainly  rare.  For  those  that  we  ordinarily  run 
acj'Oss,  with  more  or  less  severe  attacks  of  liver  colic,  gastric 
ca  tarrh  and  jaundice,  I  prescribe  a  strict  diet,  a  regular  mode 
of  living  and  Ems,  or  Vichy,  or  Yessentucki,  or  Karlsbad  (less 
frequently  Marienbad),  in  accord  with  the  peculiarities  of  the 
case.  Calomel  is  less  frequently  administered  in  fresh,  recent 
cases  :  much  oftener  for  patients  who  had  suffered  for  a  long 
time  from  liver  colic  and  deranged  digestion,  who  have  more 


—  416  — 

than  once  gotten  well,  who  had  been  subjected  to  recurrent 
attacks  of  the  disease,  have  grown  weak  and  thin  and  are  not 
benefited  any  more  by  the  use  of  mineral  waters.  As  the 
principal  indication  for  the  use  of  calomel  I  consider  not  so 
much  the  severity  of  the  individual  attacks,  as  the  presence  of 
the  constant  pain  in  the  region  of  the  gall-bladder,  generally 
in  the  liver,  and  the  fever :  calomel  administered  in  such  cases 
has  always  produced  results  as  splendid  as  it  did  in  the  above- 
mentioned  cases.  In  a  small  minority  of  cases  (less  than  in 
one  out  of  every  twenty),  without  undoubted  symptoms  of 
pericystitis,  I  ordered  leeches  —  from  six  to  ten  alongside  the 
right  hypochondrium. 

For  the  sake  of  precision  I  must  tell  you  also  of  a  case  which 
was  not  benefited  by  calomel ;  however,  this  case,  which  etiolog- 
ically  belongs  perhaps  to  the  class  of  cases  under  consideration, 
is  certainly  one  of  a  different  nature.  The  patient,  a  female  of 
sixty,  strongly  built,  had  since  her  fortieth  year  suffered  from 
liver  colic,  had  frequently  used  the  mineral  waters,  but  did  not 
complain  of  any  colic  lately.  Without  anything  to  account  for 
them,  there  appeared  febrile  attacks  of  a  pyaemic  nature,  against 
which  enormous  doses  of  quinine  proved  ineffectual  (the  salyci- 
lates  were  as  yet  not  in  use  at  those  times).  As  no  cause  for 
these  attacks  could  be  determined,  we,  guided  by  the  anamnes- 
tic data,  concluded  them  to  be  probably  due  to  abscesses  of  the 
liver,  as  caused  by  biliarj^  calculi,  although  there  was  neither 
jaundice  nor  pains  in  the  region  of  the  liver,  neither  spontane- 
ous nor  on  pressure  (the  liver  was  felt  to  be  diminished  in 
size).  The  appetite  became  somewhat  livelier  and  the  next  at- 
tack of  fever  came  later;  however  the  attacks  continued  as 
before  without  cessation  up  to  the  time  she  died.  The  case 
was  one  in  private  practice,  and  no  autopsy  was  permitted. 

I  usually  prescribe  one  grain  of  calomel  every  hour,  and  after 
the  sixth  dose  (either  before  or  after  it,  in  accord  with  the  pe- 
culiarities of  the  case)  every  two  hours,  and  after  the  first  good 
calomel  evacuation  I  stop  the  drug. 

Ordinarily  I  give  no  more  than  twelve  grains  in  succession, 
and  in  case  the  patient  has  no  loose  stools  I  give  a  tablespoon- 
f ul  of  castor  oil  two  hours  after  the  last  dose ;  but  this  is  rarel}^ 
necessary.  I  have  observed  that  patients  in  whom  castor  oil 
causes  nausea,  bear  it  better  after  calomel.  Diarrhcea  after 
calomel  is  of  rather  I'are  occurrence  and  is  easily  checked  by  a 
few  drops  of  simple  tincture  of  opium.  Larger  doses  of  calo- 
mel and  more  frequently  administered  I  found  unsuitable  :  they 


—  417  — 

weaken  the  patient  who  usually  suffers  already  with  poor  health, 
and  cause  obstinate  diarrhoea.  With  the  very  first  dose  of  calo- 
mel that  I  prescribe,  I  advise  gargling  with  a  solution  of  potas- 
sium chlorate  (3ij  to^vj),  and  continue  this  last  for  a  few  days 
after  the  use  of  calomel  has  been  stopped.  I  never  observed 
any  trouble  in  the  gums  while  taking  such  precautions. 

We  hear  at  times  that  calomel  acts  only  as  a  laxative. 
Neither  the  pharmacological  nor  the  clinical  data  present  a  ba- 
sis for  such  a  view.  But  even  if  calomel  acts  only  as  a  laxa- 
tive, are  then  all  the  laxatives  alike  ?  Ignorant  indeed  would 
be  the  practitioner  who  would  consider  all  the  laxatives  alike, 
without  differentiatmg  the  cases  where  each  of  them  may  be 
employed. 

Facts  have  made  it  sufficiently  clear  to  me.  that  whether  as 
a  laxative  or  otherwise,  calomel  will  in  certain  cases  do  what,  in 
the  present  condition  of  therapeutics,  no  other  laxative,  nor 
generally  any  other  drug,  can  do.  Many  a  time  have  I  seen 
cases  which,  just  as  the  second  related  case,  were  not  benefited 
by  the  various  laxatives,  including  castor  oil,  when  the  con- 
dition of  the  patient  remained  the  same,  or  became  frequently 
worse,  while  calomel  turned  the  scales. 

As  far  as  the  particular  comparison  between  calomel  and  cas- 
tor oil  is  concerned,  I  will  say  this  much :  In  the  above-described 
diseases  of  the  biliary  passages,  castor  oil  can  hardly  at  all  be 
compared  to  calomel :  it  only  causes  a  loose  stool,  without  pro- 
ducing the  characteristic,  in  the  case  of  calomel,  dark-greenish, 
abundant  bile-colored  evacuations  ;  nor  does  it  produce  that  ef- 
fect on  the  morbid  phenomena  in  the  domam  of  biliary  passages. 
which  is  so  pronounced  and  so  constant  after  the  use  of  calo- 
mel. Besides,  it  is  badly  borne  in  such  cases,  ofttimes  induc- 
ing vomiting  and  aggravating  the  disease.  In  erysipelas  of  the 
face,  in  typhoid  fever,  croupous  pneumonia  and  acute  Bright's, 
there  is  some  similarity  in  the  nature  of  the  effect,  but  an 
enormous  difference  in  the  degree  of  this  last.  And  to  ad- 
mmister  —  with  the  purpose  of  obtaining  an  effect  similar  to 
that  obtained  from  calomel  —  doses  of  castor  oil,  larger  than  those 
used  for  ordinary  laxative  effects,  would  be  an  unfortunate  pro- 
cedure, as  even  the  ordinary  doses  are  not  borne  as  well  as 
those  of  calomel,  while  larger  ones  would  affect  injuriously  the 
stomach  and  the  mtestines,  which  circumstance  would  result 
not  in  improving,  but  in  aggravating  the  condition  of  the  pa- 
tient. 

Hypertrophic  cirrhosis  of  the  liver.  —  I  observed  only  one 


—  418  — 

case,  to  which  I  shall  refer  here.  Novemher  8, 1883, 1  was  called 
for  the  first  time  to  see  N.  N.  The  patient,  twenty-three  years  old, 
had  long  since  ceased  to  obey  his  elders,  was  extremely  irritable, 
formerly  neglected  his  health  entirely,  and  during  his  illness 
lost  his  faith  in  medicine,  did  not  follow  his  physician's  instruc- 
tions, and  is  in  addition  to  this  very  weak,  so  that  it  is  almost 
impossible  to  obtain  from  him  any  information  as  to  his  past. 
All  the  data,  which  we  succeeded  in  obtaining  from  him  and 
from  his  relatives  after  he  improved,  may  be  summed  up  as 
follows.  When  fifteen  years  of  age,  patient  had  an  attack  of 
diphtheria,  after  which  there  remained  some  hoarseness  (paresis 
of  the  left  vocal  cord).  During  several  summers  he  suffered  from 
intermittent  fever,  one  or  two  attacks,  which  yielded  quickly 
to  quinine.  Patient  took  to  drinking  during  the  last  four  years, 
and  exclusively  wine  at  that,  Madeira  (never  drank  any  brandy), 
in  great  quantities,  from  three  to  five  bottles  per  day,  so  that 
he  was  tipsy  almost  every  day.  The  last  year  and  a  half  he 
became  very  irritable  and  lost  his  appetite.  In  the  summer  of 
1883,  he  began  to  have  daily  vomiting  in  the  morning,  after  the 
first  glasses  of  Madeira.  During  the  month  of  September  pa- 
tient spent  much  of  his  time,  late  in  the  evenings,  in  excursions, 
garden-parties  and  during  bad  weather  was  subjected  to  attacks 
of  cold.  By  the  middle  of  September  he  became  feverish, 
lost  his  appetite  completely,  and  the  whites  of  his  eyes  became 
yellow.  A  physician  was  called  in  September  25th,  and  detected 
an  enormous  enlargement  of  the  liver.  At  the  advice  of 
another  physician  he  gave  up  drinking  wine,  and  from  October 
11th  drank  natural  Karlsbad  water,  one  and  a  half  glasses  per 
day,  somewhat  warmed.  During  the  time  that  he  was  treated 
with  the  Karlsbad  water,  patient  had  every  day  ten  to  fifteen 
loose  stools,  not  more  than  a  teaspoonful  at  a  time  (hardly  one 
half  a  glassful  during  the  twenty-four  hours),  of  a  painful 
character ;  since  then  the  abdomen  became  constantly  sensitive, 
especially  so  in  the  left  lower  half.  The  jaundice  became  aggra- 
vated during  this  period,  the  abdomen  increased  in  size  (the 
physician  diagnosed  abdominal  dropsy),  and  there  appeared 
(edema  of  the  legs.  The  sleep  became  very  poor.  October  22d 
and  23d  the  patient  took  infusion  of  digitalis  (from  ten  grains), 
but  without  any  result.  October  28th,  he  began  to  take  adonis 
vernalis,  but  did  not  even  take  the  whole  of  the  first  bottle. 
Since  then  and  until  November  3d,  he  took  pills  made  of  extr.  rhei 
compos.  3j,  extr.  hyosciami  gr.  ij  (after  he  stopped  taking  the 
Karlsbad  water  he  became  constipated),  which  produced  loose 


—  419  — 

stools,  similar  to  those  caused  b}^  the  Karlsbad  water :  some  ten 
to  fifteen  stools  per  day,  not  more  than  one  teaspoonful  at  a 
time.  From  November  Ist  to  10th,  patient  took  potassium  bromide 
(ten  to  fifteen  grains  at  bed-time)  for  his  poor  sleep,  without 
any  success,  and  during  both  days  of  November  5th  and  6th,  he 
took  fifteen  grains  of  potassium  iodide. 

Status  November  8th,  1883.  —  Patient  is  generally  surrounded 
by  excellent  conditions  of  life  ;  but  the  room  which  he  preferably 
occupies  at  the  present  time,  is  situated  m  a  corner,  and  has 
many  windows,  while  near  by  the  patient's  very  bedstead 
is  a  door,  through  which  there  blows  a  strong  draught  (along- 
side of  this  is  a  cold  watercloset).  This  notwithstanding,  pa- 
tient stubbornly  refuses  to  change  his  room  ;  besides,  he  is  very 
weak.  Only  two  weeks  later,  when  he  improved  somewhat  and 
grew  more  obedient,  we  succeeded  in  removing  him  into  a  large, 
spacious,  entirely  satisfactory  room,  and  this  removal  had  in- 
duced a  favorable  change  in  his  condition.  Outside  of  four 
glasses  of  milk  a  day,  patient  neither  eats,  nor  drinks  anything  : 
drinks  neither  wine  nor  tea,  does  not  smoke  (formerl}^  he  drank 
tea  and  smoked). 

,  Patient  is  of  a  weak  constitution  :  he  is  tall,  and  has  a  nar- 
row chest.  Is  extremely  weak  and  emaciated  ;  the  abdomen  is 
enormously  enlarged,  the  legs  are  oedematous  almost  up  to  the 
kneds.  The  whites  of  the  eyes  are  moderately  yellow  ;  the 
skin'  is  yellowish  at  some  places,  light-olive  colored  in  others. 
At  the  present  time  (August,  1884),  when  the  patient,  as  we 
shall  see,  improved  greatly,  and  the  evacuations  for  the  last  six 
months  became  normally  colored,  the  color  of  the  skin  is  light 
olive.  Patient  asserts  that  his  skin  was  thus  colored  for  a  very 
long  time,  long  before  the  appearance  of  the  evident  jaundice 
in  September,  1883.  The  tongue  is  normal.  There  are  no 
gastric  disturbances,  such  as  belching,  pyrosis,  nausea,  vomiting, 
sensation  of  heaviness  and  pain  in  the  region  of  the  stomach, 
either  spontaneous  or  induced  by  pressure.  As  mentioned  al- 
ready, he  has  some  ten  to  fifteen  stools  daily,  a  teaspoonful  at 
a  time  :  the  evacuations  are  loose,  whitish,  slightly  but  still  sure- 
ly colored  by  bile,  and  contain  some  mucus.  There  are  un- 
doubted symptoms  of  accumulated  fluid  in  the  abdominal  cavity. 
The  circumference  of  this  last  at  the  level  of  the  umbilicus  is 
95  c.  m.,  the  distance  between  the  xyphoid  cartilage  and  the 
symphysis  pul^is  is  12  c.  m.  But  the  abdominal  walls  are  fla]> 
b}',  not  distended,  and  extremely  thin  (on  account  of  the  extreme 
general  emaciation),  so  that  examination  of  the  abdomen  is  eas- 


—  420  — 

ily  made.  The  subcutaneous  abdominal  veins  are  not  distended. 
.There  is  constant  pain  in  the  left  lower  half  of  the  abdomen, 
which  is  increased  on  pressure  and  at  times  after  evacuations. 
The  amount  of  urine  is  350  to  400  c.  c.  a  day :  it  is  very  con- 
centrated, gives  the  reaction  of  the  biliary  pigments  and  contains 
some  albumen ;  at  times  there  are  found  in  the  urinary  sedi- 
ment uric  acid  cylinders.  The  spleen  is  slightly  enlarged,  not 
sensitive.  The  liver  is  enormous :  everj^where  equable,  preserv- 
ing its  normal  shape,  and  reaching  beyond  the  border  of  the 
ribs  and  down  to  the  umbilicus.  The  surface  of  the  liver  is 
perfectly  smooth,  not  presenting  the  least  protuberance ;  the 
anterior  border  is  sharp.  The  liver  feels  very  hard  and  is 
entirely  insensitive  to  pressure ;  there  never  were  nor  are  there 
now  any  spontaneous  pains  in  the  region  of  this  organ.  I  must 
repeat  again  that  the  extreme  thinning  out  (with  the  general 
emaciation)  and  flabbiness  of  the  abdominal  walls  enabled  us  to 
palpate  the  liver  with  an  ease,  that  is  only  rarely  possible. 
Percussion  of  the  superior  border  of  the  liver  shows  it  to  be 
somewhat  higher  than  normally.  The  respiratory  organs  are 
normal ;  the  condition  of  the  larynx  was  alluded  to  above.  The 
heart-beat,  perceptible  in  the  mammillary  line,  is  diffuse,  but 
weak ;  there  is  a  dull  sound  in  the  region  of  the  heart  in  the 
normalline;  the  tones  are  clear.  The  pulse  is  110  to  120,  ex- 
tremely weak ;  the  arteries  are,  however,  felt  without  difficulty, 
they  are  somewhat  tortuous  and  apparently  slightly  thick- 
ened. The  patient  is  feverish :  the  evening  temperature  is  be- 
tween 37.8°  R.  (100.4°  F.)  and  38.5°  R.  (101.3°  F.^,  the 
morning  the  same  or  more  frequently  lower.  The  skin  is  dry 
and  covered  here  and  there  by  extensive  eccliymotic  spots,  which 
reappear  easily  after  a  slight  pressure.  His  sleep  is  restless 
and  lasts  only  from  three  to  four  hours  out  of  the  twenty-four. 
The  head  does  not  ache  and  is  generally  free. 

The  final  diagnostic  conclusions  are  reached  by  me  during 
the  exposition  of  the  course  of  the  disease  and  of  the  effects  of 
the  treatment,  for  in  this  way,  as  will  be  seen  later,  we  obtain 
valuable  data  for  the  diagnosis.  Let  me  only  mention  here  my 
first  suppositions.  I  certainly  could  not  stop  on  simple  hyper- 
aemia  of  the  liver,  whether  active  or  passive,  as  such  an  assump- 
tion could  not  adequately  explain  the  presence  of  jaundice,  the 
impaction  of  bile,  the  enormous  enlargement  of  the  liver  and 
the  absence  of  tenderness  in  the  same.  Cancer  of  the  liver  was 
excluded  on  account  of  the  absence  of  pains  on  pressure,  and  by 
the  results  of  palpation.   Closure  of  the  ductus  choledochus  was 


—  421  — 

excluded  by  me  in  view  of  the  absence  of  attacks  of  hepatic 
colic  in  the  past  and  the  absence  of  pain  and  sensitiveness  on 
pressure  at  the  present  time,  but  chiefly  on  account  of  the  fact, 
that  notwithstanding  the  enormously  enlarged  liver,  the  evacua- 
tions were  not  entirely  colorless,  and  contained  some  biliary 
pigment,  while  the  icterus  of  the  face,  of  the  general  integu- 
ments and  of  the  urine  was  very  moderate,  being  far  less  consid- 
erable than  when  seen  in  cases  of  closure  of  the  principal 
biliary  duct. 

Outside  of  the  hypertrophic  cirrhosis  one  would  most  certain- 
ly suspect  either  multilocular  echinococcus  or  syphilis.  Against 
echinococcus  there  was  the  shape  of  the  liver,  while  syphilis 
was  excluded  by  the  fact  that  neither  the  patient  nor  his 
parents  ever  had  this  disease.  The  presence  of  abdominal  drop- 
sy I  had  to  refer  to  peritonitis,  which  was  caused  by  a  cold 
caught  in  the  patient's  rooms  ;  the  following  facts  lead  to  such 
reasoning :  the  abdominal  pams  appeared  about  the  middle  of 
October;  for  a  whole  month  previous  to  this  the  patient  was 
confined  in  his  room,  lying  most  of  the  time  in  bed  clad  only 
in  his  undergarments,  either  covered  with  a  quilt,  or  entirely 
uncovered  when  feverish  ;  while  near  by  the  bedstead  there  was 
the  door,  either  half  or  entirely  open,  through  which  there  en- 
tered a  strong  draught  from  the  watercloset  alongside  of  it. 
The  pains  appeared  at  the  time  when  the  patient  began  having, 
thanks  to  the  Karlsbad,  ten  to  fifteen  loose  stools  per  day  ;  at 
first  they  occurred  only  with  each  inclination  to  stool,  but  later 
on  they  becaine  constant.  As  will  be  seen  further  on,  from 
the  diary  of  the  disease,  the  matter  stood  thus  : 

When  the  danger  from  further  colds  ceased,  when  the  abdo- 
men was  constantly  kept  warm,  and  when,  after  the  use  of  calo- 
mel, the  diarrhoea  disappeared  and  consequently  at  once  with  it 
there  also  passed  away  tlie  irritation  of  the  peritoneum  by  the 
intestinal  movements,  then  the  abdominal  pains  began  to  di- 
minish, so  that  even  in  two  weeks  from  the  time  I  began  my  ob- 
servation there  was  a  noticeable  diminution  of  the  abdomen 
contemporaneous  with  the  disappearance  of  the  pains.  At  that 
time  it  was  as  yet  impossible  to  diagnosticate  a  diminution  in 
the  volume  of  the  liver  even  to  the  slightest  extent ;  the  be- 
ginning of  this  process  of  diminution  was  only  observed  two  and 
one  half  weeks  later.  Finally,  notwithstanding  the  considerable 
abdominal  dropsy,  the  patient  did  not  present  the  least  sign  of 
any  distension  of  the  veins  on  the  abdommal  surface,  although 
in  view  of  his  extreme  emaciation  this  condition  could  surely  be 


—  422  — 

very  easily  perceived  ;  this  condition  of  the  veins,  as  you  know, 
is  observed  in  cases  of  abdominal  dropsy  caused  by  hepatic  dis- 
ease, on  account  of  impeded  circulation  in  the  portal  system. 

Thus  I  put  it  down  as  a  hypertrophic  (biliary)  cirrhosis  of 
the  liver,  catarrh  of  the  large  intestine,  a  peritonitis  of  moderate 
severity,  particularly  in  the  vicinity  of  the  sigmoid  flexure,  and 
also  a  possible  cirrhosis  of  the  kidneys,  this  last  in  view  of  the 
former  abuse  of  alcohol,  the  cardiac  and  arterial  phenomena, 
and  the  presence  of  albumen  and  cylinders  in  the  urine.  The 
considerable  development  of  the  cedema  of  the  legs  and  partly 
the  abdominal  dropsy  I  ascribed  to  the  failure  of  the  cardiac 
activity  induced  by  the  sudden  cessation  of  wine  drinking,  by 
the  fever  and  emaciation  ;  the  same  may  be  said  partly  in  re- 
gard to  the  poor  sleep.  Having  made  the  patient  as  comfort- 
able as  it  was  possible  in  his  own  room,  and  later,  at  the  first 
opportunity,  having  removed  him  into  another  more  satisfactory 
one,  I  advised  to  keep  the  abdomen  warm  by  the  use  of  Provence 
oil  and  a  double  abdominal  flannel  binder,  and  for  nourishment 
and  drink  to  continue  the  warm  milk  (later  on,  when  the  appe- 
tite improved,  we  added  roasted  woodcock,  without  the  skin,  and 
some  white  bread),  and  to  support  the  cardiac  activity  and  the 
nervous  functions  in  general,  he  was  given  his  habitual  nervines  : 
a  glass  of  sutticiently  strong  tea  during  the  day,  some  six  to 
eight  tablespoonfuls  of  Madeira  wine,  and  three  to  four  times  a 
day  twenty-five  drops  of  the  mixture  of  the  tinctura  valer. 
aethereae  and  liquoris  anodyni  Hoffmanni  aa.  Guided  by  my  ex- 
perience in  the  use  of  calomel  for  hepatic  colic  caused  by  biliary 
calculi,  I  decided  to  try  this  remedy  in  the  present  case.  I 
also  thought  of  applying  Spanish  flies  to  the  lower  part  of  the 
left  abdomen,  but  the  considerable  ecchymoses  just  in  this  re- 
gion prevented  me  from  doing  this  :  while  lying  on  the  left  side 
patient  pressed  his  hand  on  this  region  and  the  ecchymotic 
spots  presented  true  reprints  of  the  palm  and  of  the  fingers. 

Nov.  9. —  Gargling  of  the  mouth  with  potas.  chlorate:  this 
the  patient  continued  throughout  the  whole  period  of  treatment 
with  the  calomel,  up  to  the  end  of  June,  1884.  Six  powders 
of  calomel,  containing  one  grain  each  :  the  first  three  every 
hour;  the  others  every  two  hours.  The  sixth  was  followed  by 
abundant  and  characteristic  calomel  evacuations  of  a  dark-green 
color,  and  painless.  This  time,  as  well  as  at  other  times  later 
on,  the  patient  had  one  or  at  most  two  loose  stools  from 
calomel,  but  never  more,  always  more  or  less  abundant  and 
painless. 


—   423  — 

Nov.  10.  —  Xo  stool :  the  former  frequent  and  useless  at- 
tempts at  defecation  ceased  from  this  time  on.  The  abdominal 
pain  subsided  somewhat,  both  the  pulse  and  the  sleep  are  mark- 
edly better  :  everything  else  as  before. 

Nov.  11.  —  Three  one-grain  powders  of  calomel,  one  every 
hour.     A  good  calomel  evacuation. 

Nov.  12.  —  The  same  treatment,  the  same  result. 

Nov.  13.  —  Two  powders  —  the  same  result. 

Nov.  14,  15.,  16.  and  17.  —  He  was  not  given  an}-  calomel 
during  these  days.  Xo  spontaneous  stool :  a  clyster  caused  a 
slightly  formed  evacuation,  not  of  the  same  dark-greenish  color 
as  after  calomel,  but  colored  more  markedly  than  it  was  before, 
though  still  less  than  normal.  The  appetite  began  to  reappear, 
the  abdominal  pains  diminished,  the  sleep  is  better,  the  pulse 
fuller  and  stronger,  although  still  120  per  minute.  Everything 
else  as  before. 

Nov.  19^  20,  22,  and  23.  —  Three  grains  every  day  in  the 
former  order.     The  usual  effects. 

Nov.  2-j.  —  The  patient  is  evidently  improved :  the  appetite 
is  livelier,  the  evacuations  are  more  markedly  colored  (but  stool 
tgikes  place  only  after  a  clyster  of  warm  water  which  is  given 
every  other  day),  the  jaundice  is  less  pronounced,  the  abdominal 
pains  begin  to  disappear,  the  al)domen  not  so  large  (  oO  and  40 
cm.}, the  sleep  and  pulse  better. 

Nov.  26  and  27,  29  and  30,  Dee.  3  and  4-  —  Three  grains  of 
calomel  as  Ijefore.  The  usual  calomel  stool,  less  abundant  than 
formerly.      The  improvement  continues  little  by  little. 

Dec.  7  and  8.  —  Four  grains  of  calomel  daily  ;  no  stool. 

Dec.  9.  —  Three  doses  of  calomel,  two  grains  every  two  hours. 
Four  hours  after  the  last  dose  a  tablespoonful  of  castor  oil. 
Abundant  calomel  evacuations. 

Dec.  11,  12  and  13.  —  Appetite  markedly  better.  Stool 
either  spontaneous,  or  by  clyster,  fairly  well  colored,  but  by  far 
not  normally.  The  jaundice  of  the  eyes  and  skin  is  disappear- 
ing ;  but  the  olive  color  has  remained  until  now.  Xo  abdominal 
pain.  But  here  I  will  note  a  most  important  fact :  from  this 
time  on  the  amount  of  urine  has  suddenly  increased,  up  to  900 
or  1,000  c.c.  in  the  twenty-four  hours,  and  it  became  limpid  and 
free  from  any  biliary  pigment :  still  there  is  some  albumen  as 
yet ;  the  febrile  condition  diminished.  The  fever  continued 
for  another  six  weeks  tip  to  January  2 2d ;  but  instead  of  the 
former  evenmg  temperature,  87.8°  R.  (100.4°  F.^  to  38.5°  R. 
(^101.3°  #.),  and  at  times  the  same  in  the  morning,  the  even- 


—  424  — 

ing  temperature  was  only  37.6°  R.  (99.6°  F.)  to  37.8°  R. 
.(100.4°  #.),  and  the  morning  about  37°  R.  (97.6°  F.).  During 
these  days  we  could  for  the  first  time  diagnosticate  a  slight 
diminution  in  the  size  of  the  liver.  Sleep  and  pulse  (110)  still 
better.  No  fresh  ecchymotic  spots  appeared  agam.  As  regards 
treatment  we  must  add  that  during  the  past  month  the  patient 
was  given  four  times  quinine,  twice  in  five-grain  doses  on  the 
days  when  he  did  not  get  any  calomel.  The  quinine  was  well 
borne  by  the  stomach,  but  failed  to  exert  any  influence  on  the 
fever. 

Dec.  25.  —  The  dimensions  of  the  abdomen  are  78  and  33  cm. 
The  cedema  of  the  legs  is  rapidl}^  dimmishing.  Stool  agam  only 
by  the  aid  of  clysters,  the  evacuations  less  in  number  and  their 
color  paler. 

Dec.  26  and  27.,  29,  30  and  31.  —  Three  one-grain  doses  of  calo- 
mel, one  every  hour.     A  moderate  calomel  stool. 

Jan.  3,  ISSJf.  —  Three  one-grain  doses  of  calomel,  one  every 
hour.     No  stool. 

Jan.  4--  —  Three  doses  of  calomel,  two  grains  every  two 
hours,  later  a  teaspoonful  of  castor  oil.  Abundant  calomel 
evacuation. 

From  January  5th  up  to  22d,  equable  improvement  continues. 
On  that  day  the  symptoms  of  accumulation  of  fluid  in  the  abdo- 
men, the  cedema  of  the  legs,  as  well  as  the  fever,  have  all  en- 
tirely disappeared.  The  liver  continues  decreasing  in  size.  Dur- 
ing this  time  the  patient  was  given  two  soap-baths  so  as  to 
clean  his  skin ;  this  weakened  him.  During  the  last  days 
the  stool  is  again  worse;  it  is  necessary  to  resort  to  a  clyster, 
the  evacuation  is  insufficient  and  its  colormg  is  again  lighter. 

Jan.  23.  —  Four  doses  of  calomel,  one  grain  every  hour.  No 
effect. 

Jan.  24.  —  Three  doses  of  calomel,  two  grains  every  two 
hours.  Abundant  calomel  evacuations.  From  that  time  un- 
til the  present  (August,  1884)  the  patient's  condition  con- 
tinued to  improve.  Little  by  little  the  appetite  grew  better 
than  it  ever  was  during  the  last-  three  years.  The  liver  con- 
tinued to  shrink  in  size,  although  slowl}^  so.  The  albumen 
in  the  urine  amounts  only  to  a  slight  reaction,  but  it  did  not 
disappear  entirely.  The  sleep  became  entirely  normal,  while 
the  mental  state,  as  compared  with  what  it  was  before,  is 
marvellously  good.  Patient  began  to  take  on  flesh  and  gather 
strength  little  by  little.  The  evacuations,  after  the  abundant 
calomel  stool,  were  for  a  few  days  spontaneous,  in  sufficient 


—  426  _ 

quantity  and  fairly  well  colored ;  but  later  on  they  grew  less 
abundant  and  became  less  colored,  till  finally  a  resort  to  clyster 
was  had  again.  We  then  administered  calomel  again  —  from 
now  on  always  in  three  two-grain  doses,  every  three  hours 
without  any  castor  oil  —  and  obtained  the  usual  good  results. 
Thus  calomel  was  given  February  6th,  16th  and  26th,  March 
6th  and  30th,  April  14th,  May  1st  and  16th,  and  the  last  time 
June  20th.  Between  March  6th  and  80th,  when  calomel  was 
not  administered,  he  was  given  for  about  two  weeks  fiv  of 
Ems-Kesselbrunnen,  three  times  in  the  morning,  slightly 
warmed,  without  the  least  effect  on  the  patient's  condition. 
At  the  same  time,  after  the  Ems,  in  view  of  the  fact  that  not- 
withstanding the  absence  of  fever  the  pulse  was  still  frequent 
(100),  we  tried  digitalis  (24  grains  in  an  infusion  during  three 
days),  but  this  also  failed  to  exert  any  effect.  The  pulse  grew 
less  and  less  frequent  only  contemporaneously  with  the  improve- 
ment in  health,  but  even  now  it  is  about  90.  Finally  for  the 
sake  of  completeness  we  must  add  that,  thanks  to  the  prolonged 
recumbent  posture,  usually  on  the  back,  with  legs  flexed  at  the 
knees,  the  patient  developed  contractures  and  paresis  of  certain 
muscles  of  both  legs  and  feet.  Gradual  exercises  by  walking, 
massage  and  the  induced  current  removed,  though  slowly,  these 
conditions,  and  with  this  the  muscles  have  markedly  mcreased 
in  size.  vSmce  March  the  induced  current  was  applied  to  the 
abdomen  so  as  to  act  on  the  intestines  and  liver.  This  has 
apparently  also  exerted  some  influence  on  the  constipation ; 
whether  or  not  the  liver  was  influenced,  it  is  difficult  to  say, 
as  the  liver  had  diminished  in  size  even  before,  and  since  this 
time  it  has  diminished  but  little  (we  also  continued  the  use  of 
calomel). 

At  the  present  time  (the  end  of  August,  1884)  the  patient's 
condition  is  as  follows  :  while  living  during  the  summer  in 
the  country  he  walks  a  great  deal.  For  more  than  two  months 
he  had  taken  no  calomel,  nor  any  other  treatment.  The 
appetite  is  good,  the  digestion  is  perfectly  regular  (he  resorts 
to  clysters  but  very  seldom),  his  sleep  is  excellent,  the  mental 
condition  good,  the  patient  has  grown  stout  and  strong.  The 
urine  still  contains  some  albumen,  but  in  a  very  trifling  amount ; 
the  arteries  and  the  heart  are  in  the  former  condition,  the  pulse 
is  still  about  90.  The  liver  is  much  smaller  m  size  than  it 
was  before,  but  still  certainly  larger  than  the  normal  liver ;  it 
reaches  two  fingers'  width  beyond  the  border  of  the  ribs  and 
is  firmer  than  normally.  The  light  olive-like  color  of  the  skin 
has  not  changed. 


^  426  — 

I  will  return  now  to  the  diagnosis,  the  interest  in  which  in 
the  present  case  is  quite  evident.  The  markedly  favorable 
course  of  the  disease  compels  us  to  entirely  exclude  multiple 
eohinococcus.  It  is  otherwise  with  sj'philis :  did  we  not  treat 
a  syphilitic  liver  with  a  mercurial  preparation,  calomel  ?  This 
supposition  cannot  be  entertained  for  the  following  reasons  : 
neither  the  patient's  father  (now  dead,  but  whom  I  knew 
well)  nor  his  mother  had  syphilis.  The  patient  himself,  who 
had  now  acquired  boundless  implicit  confidence  in  the  physi- 
cian, and  who  became  very  docile,  declares  that  he  was  gener- 
ally averse  to  sexual  intercourse,  had  never  suffered  from  any- 
thing, not  even  gonorrhea,  that  he  never  had  any  falling  out 
of  the  hair  (this  is  now  remarkably  thick),  nor  any  eruptions 
or  ulcers,  nor  any  nocturnal  or  other  pains.  The  results  ob- 
tained by  palpating  the  liver,  namely :  the  perfect  smoothness 
of  its  surface,  the  regularity  of  its  shape  and  its  shaip,  free 
border,  also  speak  agamst  syphilis;  the  slight  coloring  of  the 
evacuations  and  the  jaundice  are  also  unlikely  to  be  seen  in 
syphilis  of  the  liver. 

Finally,  the  treatment  itself :  calomel  was  always  administered 
so  as  to  cause  loose  stools,  which  it  did  :  and  it  was  given  at 
intervals  which  became  more  and  more  prolonged.  Every 
experienced  physician  is  well  aware  of  the  fact,  that  success  in 
treating  syphilis  of  the  liver,  or  generally  any  severe  case  of 
syphilitic  affection,  cannot  be  attained  by  such  mtensive  mer- 
curial treatment  applied  in  such  a  manner,  and  that  it  can 
hardly  be  expected  without  a  simultaneous  use  of  large  doses 
of  potassium  iodide.  Therefore,  even  with  greater  probability 
than  at  the  beginning  of  my  observation,  can  I  view  this 
case  as  one  of  hypertrophic  cirrhosis  of  the  liver.  It  is 
worth  our  while  to  note  the  following  :  the  etiology  of  hy- 
pertrophic or  biliary  cirrhosis  of  the  liver  made  clear  the  fact, 
that  contrary  to  the  simple  Laennec  cirrhosis,  it  is  seen  in  those 
who  abuse  wine,  and  not  whiskey.  The  anamnesis  of  the  case 
described  by  me  substantiates  this  fact :  our  patient  always 
di'ank  Madeira,  never  any  whiskey. 

A  few  words  concerning  the  prognosis.  Is  the  improvement 
in  the  condition  of  the  liver  of  a  lasting  nature  ?  If  the  patient 
will  lead  as  regular  a  mode  of  living  as  he  does  now,  then  the 
recurrence  of  the  icterous  symptoms  seems  to  me  but  slightly 
probable,  and  even  if  it  will  occur,  then  in  the  presence  of  the 
effective  influence  thereon  of  calomel,  it  will  present  no  partic- 
ular danger.     It  is  otherwise  if  we  were  to  ask,  whether  or  not 


—  427  — 

the  other  variety  of  hepatic  cirrhosis  —  the  Laennec  cirrhosis 
—  could  develop  ;  this  however  is  a  question  we  are  unable  to 
answer  at  the  present  time.  The  albuminuria  and  the  arterial 
and  cardiac  phenomena  have  certainly  a  very  serious  significance 
as  regards  the  future  state  of  the  patient.  Be  as  it  may,  the 
improvement  m  the  patient's  condition  under  the  given  circum- 
stances is  marvellous :  the  patient's  relatives,  who  last  autumn 
lost  all  hopes  for  his  recovery,  inquire  of  the  physician  about  the 
advisability  of  having  the  patient  married. 

Facial  Erysipelas. —  For  young  persons  with  a  good  heart 
and  regular  digestion,  I  give  quinine  until  a  slight  noise  in  the 
ears  is  produced,  and  if  the  conditions  permit  I  order  general 
baths  of  24°  to  20°  it.,  and  apply  cold  compresses  to  the  parts 
affected  by  erysipelas.  Quinine  exerts  a  favorable  effect  in 
lowering  the  temperature ;  the  same  may  be  said  of  the  cold 
compresses,  which,  together  with  the  quinine,  may  even  directly 
interrupt  the  process,  when  the  fever  and  the  further  spread  of 
the  erysipelas  cease.  But  there  occur  cases  of  facial  erysipelas 
in  persons  of  advanced  age  whose  cardiac  activity  and  digestive 
powers  are  below  normal,  who  suffer  from  dyspepsia  or  gastric 
catarrh  with  a  tendency  to  constipation,  with  attacks  of  he- 
patic colic,  either  m  the  past  or  at  the  present  time,  and  in  whom 
the  evacuations  are  not  normally  colored.  In  such  cases  quinine 
is  badly  borne  by  the  stomach,  and  so  are  the  cold  baths,  in 
view  of  the  abdominal  distension  caused  by  meteorism  and  the 
weak  cardiac  activity.  Neither  of  the  above  drugs  gives  as  good 
results  hi  such  cases,  as  in  those  of  the  preceding  class.  I  replace 
them  by  calomel,  in  one-grain  doses  every  hour  (the  last  doses 
every  two  hours),  till  looseness  of  the  bowels  is  established  ;  if 
this  does  not  take  place  after  twelve  grains,  I  administer  castor 
oil.  I  never  omit  in  these  cases  the  potassium  chlorate  gar- 
gling, A  good  loose  stool  is  followed  by  improvement  in  the  me- 
teorism, the  respiration  and  the  condition  of  the  head  are  made 
easier,  the  temperature  is  lowered  for  one  or  two  days,  the  pa- 
tient is  enabled  to  sleep  quietly  one  or  two  nights.  At  times 
the  temperature  will  fall  to  the  normal  without  ever  rising  agam  ; 
then  the  further  spread  of  the  erysipelas  ceases.  But  if  the 
temperature  rises  again,  if  the  erysipelas  spreads  further  and 
the  condition  of  the  patient's  strength  is  satisfactory,  then  I  ad- 
minister calomel  for  the  second  time  in  the  former  fashion.  We 
never  have  to  administer  the  calomel  more  than  twice,  either 
because  the  erysipelas  ceases,  or,  in  case  it  does  continue,  because 
the  fever  is  slight,  and  the  patient's  strength  is  affected  by  the 


—  428  — 

continuance  of  the  disease.  I  then  prescribe  moderate  doses  of 
quinine,  which  is  better  borne  then,  after  an  improvement  in  the 
condition  of  the  digestive  organs  has  taken  place,  thanks  to 
the  use  of  calomel. 

Typhoid  Fever.  —  Like  many  others,  I  also  witnessed  the 
value  of  calomel  in  this  disease.  In  accord  with  others,  I  ad- 
minister it  during  the  iirst  week  and  usually  not  later  than  on 
the  eighth  or  ninth  day  of  the  disease.  I  give  it  when  there  is 
no  diarrhoea,  when  the  strength  of  the  patient  permits  it,  and  I 
must  say  again  I  particularly  insist  on  giving  it  to  patients 
with  a  condition  of  the  digestive  organs  as  described  above  in 
touching  on  the  second  class  of  erysipelatous  patients.  The 
loose  stool  after  calomel  diminishes  the  meteorism,  relieves  the 
breathing  and  the  condition  of  the  head,  causes  a  fall  of  tem- 
perature for  one  or  two  days,  and  enables  the  patient  to  spend 
one  or  two  quiet  nights  (he  sleeps  better  and  is  less  delirious). 
The  favorable  effect  of  two  good  days  at  this  period  on  the 
further  course  of  the  disease  is  not  to  be  underestimated.  I 
o'ive  the  calomel  here  in  the  same  manner  as  I  administer  it  for 
erysipelas,  but  I  do  not  repeat  it,  out  of  apprehension  of  weaken- 
ing the  patient ;  this  apprehension  is  of  even  greater  importance 
in  typhoid  fever  than  in  erysipelas.  I  cannot  help  observing 
here  that  the  assumed  specific  effect  of  calomel  on  the  intes- 
tinal microbes  of  the  typhoid  fever  does  not  seem  to  me  partic- 
ularly probable.  We  fail  to  observe  a  sudden  interruption  of 
the  fever  by  calomel,  as  we  do  in  the  case  of  quinine  in  mala- 
ria ;  we  only  witness  here  a  favorable  effect  on  the  further 
course  of  the  disease,  just  as  we  did  in  erysipelas,  and,  as  we 
shall  see  presently,  in  pneumonia,  and  in  acute  Bright's,  —  in 
processes  which  have  nothing  to  do  with  intestinal  microbes. 
On  the  contrary  m  cholera,  in  which  we  would  most  certainly 
expect  an  effect  from  the  calomel,  1  failed  to  see  the  very  least 
effect  from  it  during  the  two  severe  epidemics  in  Moscow,  of  1853 
and  1854,  when  in  my  capacity  as  a  resident  physician  in  the 
temporary  cholera  ward  of  the  university  clinic,  I  had  charge 
of  a  great  many  patients,  and  calomel  constituted  the  ordinary 
treatment  of  cholera. 

Croupous  Pneumonia.  —  During  the  first  two  years  of  my 
medical  practice  I  used  digitalis,  but  it  did  not  prove  efficacious, 
at  times  it  was  even  harmful,  and  since  then  I  never  use  it  in 
pneumonia.  In  several  cases  I  tried  cold  baths  and  concluded 
that,  although  the  patient  may  bear  them,  they  hardly  profit  by 
them,  if  we  except  a  trifling  fall  of  the  temperature  of  but  short 


—  429  — 

duration.  My  acquaintance  with  cairine  did  not  tempt  me  into 
trying  this  drug.  From  qumine  I  only  obtained  a  fall  of  tem- 
perature of  short  duration,  and  this  only  when  administered  in 
enormous  doses  which  are  but  with  difficulty  borne  by  the  stom- 
ach and  the  nervous  system ;  I  therefore  discarded  this  drug,  ex- 
cept in  some  protracted  cases,  when  the  fever  is  of  a  strongly 
remittent  type  in  the  morning,  and  moderate  doses  of  quinine 
become  effective.  Even  less  suitable  for  pneumonia  do  I  con- 
sider sodium  salycilate,  especially  in  view  of  its  action  on  the 
heart.  My  principal  remedy  in  the  treatment  of  pneumonia, 
outside  of  the  usual  symptomatic  drugs  (as  Dover's  powders 
for  the  cough  in  the  beginning  when  there  is  but  little  or  no  ex- 
pectoration, wine  for  the  heart,  etc.),  has  been  calomel  until  now, 
and  is  even  at  the  present  time  when  antipyrin  and  antif ebrin  are 
introduced  mto  practice.  I  administer  it  in  the  same  manner 
as  for  erysipelas,  namely  in  sthenic  cases  of  pneumonia,  to  pa- 
tients of  strong  constitution,  when  the  condition  of  their 
strength  is  good,  mostly  during  the  iirst  days  of  the  disease,  and 
particularly  when  the  condition  of  the  digestive  organs  resem- 
bles that  described  above  in  connection  with  er3-sipeifttous  pa- 
tients of  the  second  category.  The  effect  is  the  same  as  in  fa- 
cial erysipelas  and  typhoid  fever :  the  looseness  of  the  bowels  is 
followed  by  a  decrease  in  the  size  of  the  abdomen,  by  relief  of 
the  respiration  and  of  the  condition  of  the  head,  by  a  fall  of  the 
temperature  and  by  at  least  one  quiet  night.  Such  a  relief  at  this 
stage  of  a  disease  of  the  limited  duration  of  croupous  pneumonia, 
has,  according  to  my  observations,  the  same  favorable  influence 
on  the  further  course  of  the  affection,  as  it  has  in  typhoid  fever, 
if  not  a  better  one :  at  times  the  fall  of  temperature  caused  by 
the  calomel  passes  directly  into  the  crisis.  We  usually  do  not 
have  to  repeat  the  calomel  in  view  of  the  rapid  course  of  the 
disease  and  the  danger  of  weakening  the  patient. 

Acute  Nephritis.  —  In  those  cases  which  developed  mdepend- 
ently  of  any  preceding  infectious  disease,  and  also  in  those  seen 
during  the  puerperal  period,  but  not  connected  with  puerperal 
septicaemia,  I  administer  calomel  for  the  first  days  of  the 
disease,  in  the  same  manner  as  described  in  connection  with 
erysipelas,  with  the  identical  good  result,  as  shown  by  the  con- 
siderable fall  of  the  temperature  and  the  diminution  of  the  lo- 
cal phenomena :  the  pains  in  the  region  of  the  kidneys  grow 
weaker,  the  urine  increases  in  amount  and  becomes  limpid.  If 
the  temperature  after  this  rises  again,  and  the  condition  of  the 
strength  is  fair,  then  I  sometimes  resort  to  a  repeated  use  of 
calomel,  just  as  I  do  in  erysipelas. 


—  430  — 

As  contraindications  to  the  use  of  calomel,  outside  of  the 
weakness  of  the  patient  (as  evidenced  principally  by  the  pulse), 
are  considered  severe  diarrhceas  with  abundant  exhausting 
evacuations,  but  not  such  as  were  described  when  we  discussed 
the  case  of  the  patient  suffering  from  hypertrophic  cirrhosis  of 
the  liver:  such  a  diarrhoea  is  on  the  contrary  an  indication  for 
the  use  of  calomel. 

An  Additional  Note  Appended  to  the  Edition  of  1895. 

I  will  touch  now  on  the  indications  for  the  use  of  calomel  in 
diseases  of  the  biliary  passages. 

In  my  former  communication  I  mentioned  two  affections  of 
the  biliary  passages  in  which  calomel  should  be  used,  namely, 
acute,  particularly  febrile,  cases  of  hepatic  colic,  and  hyper- 
trophic cirrhosis  of  the  liver.  Further  observations  compel  me 
to  widen  the  range  of  these  indications  :  calomel  should  be  used, 
for  hypertrophic  cirrhosis  of  the  liver,  in  all  (not  only  acute) 
cases  of  biliary  calculi  and  in  catarrhal  jaundice. 

The  indication  for  the  use  of  calomel  in  biliary  calculi  and  in 
catarrhal  jaundice  I  must  formulate  thus :  if  the  ordinary  meas- 
ures employed  in  the  treatment  of  the  disease,  such  as  a  regu- 
lated regimen,  diet,  at  times  warm  baths,  and  chiefly  the  use  of 
mineral  waters,  either  alkaline  or  earthy  (Contrexeville),  im- 
prove the  condition  slowly,  if  we  observe  constant  tenderness 
in  the  region  of  the  gall-bladder  (in  biliary  calculi)  or  over  the 
whole  liver  (as  in  catarrhal  jaundice),  the  more  so  if  it  be  at- 
tended with  a  febrile  condition  (as  well  as  without  it),  and  if  the 
above  alluded  to  contraindications  to  the  use  of  calomel  are  ab- 
sent, then  we  interrupt  the  use  of  the  mineral  waters  and 
administer  calomel  in  the  manner  explained  in  the  first  commu- 
nication ;  later  on  we  return  again  to  the  mineral  waters  and,  if 
necessary,  repeat  the  calomel ;  every  time  we  do  that  we  must 
of  course  put  aside  the  mineral  waters. 

To  illustrate  these  propositions  I  shall  speak  here  briefly  of 
the  following  cases. 

1.  Biliary  Calculi.  —  This  patient  was  first  treated  for  an 
exacerbated  chronic  catarrh  of  the  large  intestine. 

The  patient,  a  woman  sixty-seven  years  old,  passed  through 
an  attack  of  dysentery  four  years  ago.  She  usually  complains 
only  of  slight  dyspeptic  symptoms  (heaviness  and  belching  after 
meals),  of  pain  in  the  region  of  the  gall-bladder,  and  of  irregu- 
lar stools  since  the  attack  of  dysentery  :  either  a  constipation  or 
a  diarrhoea  for  two  or  three  days.     The  present  condition  :  an 


—  431  — 

accidental  cold  was  followed  by  loss  of  appetite,  by  the  ap- 
pearance of  nausea,  of  intestinal  pains,  and  a  feverish  condition. 
On  the  next  day  vomiting  and  diarrhoea  accompanied  b}-  severe 
intestinal  pains  :  some  insufficient  liquid  stools  mixed  with  mu- 
cus, but  without  any  blood,  three  to  four  per  hour  :  the  abdo- 
men is  distended  and  sensitive,  particularly  in  the  region  of  the 
colon.  Evening  temperature  39.2°  R.  (102,5°  FS)  ;  the  urine 
shows  the  presence  of  albumen.  In  the  evening  we  began  to 
give  her  one-grain  doses  of  calomel  every  hour.  After  the  third 
powder  the  vomiting  ceased ;  the  ninth  dose  was  followed  by 
abundant  painless  dark-green  evacuations ;  the  calomel  was 
stopped.  Patient  began  to  feel  better  at  once.  In  the  course 
of  three  daj^s  the  temperature  fell  to  the  normal ;  with  this  there 
disappeared  also  the  albumen.  The  first  three  days  after  the 
calomel  she  had  two  to  four  stools  a  day  ;  later,  one.  The  dark- 
green  color  of  the  evacuations  continued  decreasing  during  a 
whole  week.  Tannin  clysters  which  were  used  on  the  fourth 
day  after  the  calomel  brought  to  a  speedy  termination  what 
there  was  left  of  the  intestinal  catarrh. 

In  a  year  and  a  half  the  patient  presented  herself  to  me  in 
the  following  condition  :  the  nervous  system,  the  chest  (outside 
of  a  slight  atheromatosis  of  the  aorta)  and  the  kidneys  normal ; 
she  complains  of  a  constant  bitter  taste,  frequent  belching  of 
bile,  a  feeling  of  fullness  in  the  stomach,  moderate  pain  in  the 
region  of  the  gall-bladder,  aggravated  on  pressure,  and  of  con- 
stipation with  intermittent  diarrhoea.  Warmed  Ems  and  Vichy 
in  slight  quantities  proved  of  no  avail ;  while  the  bitters  (nux 
vomica  and  condurango)  brought  but  slight  relief.  I  then 
prescribed  one-grain  doses  of  calomel  every  hour ;  after  the 
third  powder  there  appeared  abundant  dark-greenish  stools 
(painless),  three  times  the  first  day,  twice  the  next  (she  was 
only  given  three  powders  of  calomel)  ;  the  above-enumerated 
symptoms  have  entirely  disappeared  both  from  the  stomach  and 
the  biliary  passages  for  a  long  time.  Only  in  the  course  of  an- 
other year  did  the  patient  present  herself  again  with  the  same 
symptoms,  but  in  a  much  lighter  degree;  the  same  plan  of 
treatment,  three  one-grain  doses  of  calomel,  and  the  same  suc- 
cess. 

In  connection  with  the  above-described  case  I  consider  it 
necessary  to  touch  upon  the  diagnosis  of  l^iliary  calculi.  Some 
consider  as  a  reliable  symptom  only  undoubted  attacks  of 
biliary  colic,  without  paying  due  attention  to  the  presence  of 
pain  in  the  region  of  the  gall-bladder,  of  which  the  patients 


—  432  — 

complain,  or  which  is  detected  by  pressure.  My  observations 
are  of  the  following  nature:  in  all  the  cases  of  biliary  calculi 
which  are  attended  by  frequent  or  infrequent  attacks  of 
biliary  colic,  there  is  observed  a  constant,  i.  e.  occurring  in 
the  intervals  between  the  attacks,  pain,  as  above-described,  in 
the  region  of  the  gall-bladder;  exceptions  to  this  are  very 
rare  indeed.  Further,  there  occur  cases  of  biliary  calculi 
where  the  above-mentioned  pain  is  seen  without  any  attacks 
of  liver  colic.  We  also  meet  various  gradations  between  these 
two  classes  of  cases  :  thus  it  happens  that  for  a  long  time  there 
is  observed  only  a  constant  pain  in  the  region  of  the  gall-blad- 
der, and  later  there  may  also  appear  attacks  of  biliary  colic  ; 
these  last  may  be  of  variable  severity,  from  the  lightest  to  the 
very  severe  ones  :  then  the  attacks  of  biliary  colic  may  cease, 
thanks  to  treatment  or  to  a  regulated  mode  of  living,  and  there 
remains  only  the  constant  pain  in  the  gall-bladder,  which  in  its 
turn  may  also  disappear.  In  view  of  all  this  I  consider  the 
above-named  constant  pain  in  the  region  of  the  gall-bladder 
as  a  certain  symptom  of  the  presence  of  biliary  calculi  therein. 

This  pain  depends  very  likely  on  a  chronic  inflammation  of 
the  walls  of  the  gall-bladder  caused  by  the  presence  of  the  calculi: 
while  the  attacks  of  biliary  colic  are  determined  by  spasms 
of  the  nervo-muscular  apparatus  of  the  bladder  and  by  the 
accompanying  neuralgia,  and  is  called  forth  by  such  mfluences 
as  traumata  (a  ride  over  a  jolting  pavement,  inconvenient 
clothing),  mental  anguish,  dietetic  errors,  and  cold,  as  when 
sitting  with  right  side  exposed  to  the  window  or  the  street 
side  of  the  house  during  the  cold  season  of  the  year,  or  while 
staying  out-of-doors  with  the  right  side  of  the  body  against  the 
cold  wind. 

2,  Catarrhal  Jaundice.  —  I  will  describe  here  one  of  the  cases 
observed  by  me.  November  12,  1890,  there  entered  our 
clinic  a  peasant,  thirty  years  of  age,  complaining  of  pain  in  the 
region  of  the  stomach,  fetid  belching,  nausea,  at  times  vomit- 
ing, and  of  jaundice  and  general  debility. 

Conditions  and  mode  of  living.  —  The  locality  is  healthy,  the 
residence  is  good,  the  working-room  is  very  hot  (patient  is 
stoker  by  occupation),  and  this  in  connection  with  a  cold 
watercloset,  and  the  necessity  of  going  out  of  the  room  often, 
gives  rise  to  frequent  colds.  During  the  summer  the  patient 
bathes  in  the  river ;  during  the  remaining  seasons  of  the  year, 
he  takes  a  weekly  bath  ;  he  is  subject  to  sweating.  Smokes 
a  little  ;  is  a  moderate  tea-drinker,  does  not  abuse  brandy.     Is 


—  433  — 

married;  is  not  affected  with  syphilis.  The  meals  are  those 
of  a  working-man,  consisting  of  dinner  and  supper.  Works 
some  twelve  houi's  a  day :  until  the  appearance  of  the  present 
disease  the  work  never  tired  him. 

Anamiiesis.  —  Patient  comes  from  a  healthy  family,  and 
until  the  last  four  years  enjoyed  good  health.  Then  he  suf- 
fered from  masked  malaria  appearing  in  the  form  of  attacks  of 
excruciatmg  pain  in  the  right  half  of  the  head,  which  at  times 
terminated  in  a  severe  nose-bleed  from  the  right  nostril,  causing 
him  to  faint.  These  pains  and  nose-bleed  continued  for  two 
years  and  almost  disappeared  when  the  patient  moved  to 
another  locality.  He  then  improved,  although  he  did  not 
enjoy  his  former  health,  and  was  free  from  any  suffermg  for 
about  one  year.  But  for  the  last  year  he  has  been  suffering 
from  dyspeptic  symptoms  pointing  to  a  gastric  catarrh  (pain 
in  the  stomach  after  a  meal,  belching  and  pyrosis ).  One  week 
ago,  as  a  result  evidently  of  a  cold,  the  patient  began  to  have  a 
febrile  attack,  pain  in  the  larynx,  hoarseness,  the  habitual 
slight  cough  became  aggravated  and  at  the  same  time  there 
appeared  vomiting  and  diarrhoea,  and  soon  after  that  also 
jaundice. 

Statu8  November  13,  1890.  —  Patient  is  of  average  constitu- 
tion, poor  nutrition,  with  jaundice  of  the  skin  and  of  the  eyes. 
The  appetite  is  very  poor,  the  meals  are  followed  by  pain  in 
the  stomach,  fetid  belching,  pyrosis  and  nausea :  while  in  the 
clinic  he  had  no  vomiting.  The  region  of  the  stomach  and  the 
liver,  i.  e.  the  subgastric  and  the  right  hypochondriac,  are  sensi- 
tive to  pressure.  The  liver  is  somewhat  enlarged.  The  spleen 
is  normal.  Had  no  stool  for  the  last  two  days  (formerly  he 
had  diarrhoea).  To-day,  a  clyster  brought  away  a  few  hard 
scybala,  almost  without  any  biliary  pigment,  of  the  color  of  clay. 
The  urine  is  of  the  color  of  beer,  gives  a  decided  reaction  of 
biliary  pigment ;  contains  neither  albumen  nor  sugar.  The 
pulse  is  not  frequent,  but  somewhat  weak.  The  organs  of 
cu'culation  and  respiration  are  normal.  The  pain  in  the  throat, 
the  hoarseness  and  the  severe  cough  disappeared  and  there 
remained  only  the  habitual  slight  cough  due  to  chronic 
lar3rngeal  catarrh.  Patient  has  no  fever.  The  sleep  is  usually 
good,  but  last  night  he  could  not  sleep  on  account  of  the  itch- 
ing of  the  skin.  The  right  half  of  the  head  is  somewhat  pain- 
ful even  now  (the  supra-  and  infraorbital  nerves  of  the  right 
side  are  sensitive  to  pressure).  Fatigue  is  at  times  accompan- 
ied  by  dizziness,  which   points    to    the    fact  that  the    former 


—  434  — 

abundant  losses  of  blood  left  the  patient  in  a  somewhat  anaemic 
condition.  Further  than  the  general  debility,  there  is  nothing 
abnormal  in  the  nervous  system  and  the  organs  of  locomotion. 

The  course  of  the  disease.  —  November  13th,  five  one-grain 
powders  of  calomel  every  hour,  and  then  five  again  every  two 
hours.  Potas.  chlor.  for  gargling  the  mouth,  four  tablespoon- 
fuls  of  wine,  diet,  warmth  (flannel)  to  the  abdomen,  and  rest. 
Loose,  soft,  dark-greenish  stools,  after  which  the  urine  became 
limpid.  Since  November  15th  he  was  given  Ems-Kesselbrun- 
nen,  half  a  glassful  three  times  a  day,  one  hour  before  a  meal, 
warmed  to  the  temperature  of  28  °  i?.,  and  when  necessary  in 
case  of  constipation,  clysters,  and  to  allay  the  itching,  to  im- 
prove the  sleep,  and  also  to  act  on  the  stomach  and  the  biliary 
passages,  warm  baths.  By  November  21st  the  dyspeptic  phe- 
nomena diminished,  the  sleep  became  better,  and  the  patient 
felt  somewhat  stronger;  but  the  icterous  phenomena  which 
yielded  to  calomel  reappeared  again  in  their  former  condition 
since  the  loth:  the  evacuations  became  colorless,  and  the  urine 
dark,  just  as  they  were  before  the  calomel  treatment.  Novem- 
ber 21st  we  repeated  calomel,  of  course  setting  aside  during  the 
21st  and  22d  the  Ems  water,  five  one-grain  powders  every  hour, 
and  then  two  more  every  two  hours.  The  effect  was  tem- 
porary, although  there  followed  a  more  prolonged,  relief  of  the 
icterous  symptoms  and  of  the  pains  in  the  region  of  the  liver, 
similar  to  what  took  place  after  the  fust  doses  of  calomel.  Then 
until  December  1st,  notwithstandmg  the  use  of  the  Ems  water, 
the  extr.  fl.  condurango  (twenty  drops  twice  a  day,  after  a  meal), 
the  warm  baths  and  a  regulated  diet,  neither  the  icterous  symp- 
toms nor  the  pain  in  the  liver  diminished  to  any  marked  ex- 
tent. I  will  say  that  after  the  second  dose  of  calomel  the 
patient  had  a  toothache,  especially  on  the  right  side,  probably  on 
account  of  carelessness  in  gargling  his  mouth  ;  but  there  were 
no  symptoms  of  mercurial  stomatitis.  December  1st  calomel  was 
administered  for  the  third  time ;  five  one-grain  powders  every 
hour,  then  three  every  two  hours,  and  in  two  hours  after  the 
last  powder  a  tablespoonful  of  castor  oil,  the  mouth  being  all 
this  time  carefully  rinsed  with  the  potassium  chlorate  solution. 
Patient  had  abundant,  loose,  soft,  dark-greenish  evacuations, 
the  last  of  which  began  to  be  graduallj^  colored  by  biliary  pig- 
ment, at  first  somewhat  weaker  than  normally,  and  later 
perfectly  normal ;  with  this  the  amount  of  biliary  pigmentation 
in  the  urine  began  to  diminish  rapidly,  and  the  general  integu- 
ments  began  to  pale.     The  pain  in  the  liver  also  disappeared 


—  435  — 

rapidly  after  the  last  abundant  calomel  evacuation.  The  pa- 
tient returned  again  to  the  treatment  with  Ems  water,  condu- 
rango  and  sometimes  baths,  which  was  interrupted  the  last  time 
by  the  calomel  treatment,  and  December  8th  left  the  clinic  en- 
tirely recovered. 

For  the  sake  of  precision  I  must  add  that  one  week  before 
the  patient  left  our  clinic  an  accidental  cold  (from  a  draught 
through  the  window)  caused  the  appearance  of  a  severe  attack 
of  his  habitual  pain  in  the  right  half  of  the  head  in  connection 
with  a  slight  febrile  condition  (37.8°i2.).  A  clyster  containing 
ten  grains  of  quinine  was  administered  (in  view  of  the  previous 
gastric  catarrh),  after  whicli,  accompanied  by  severe  noises  in 
the  ears,  the  fever  and  the  headache  disappeared  rapidly,  the 
patient  felt  himself  much  stronger,  and  the  improvement  con- 
tinued its  ordinary  course. 


SYPHILIS  OF  THE  LUNGS. 


For  the  last  two  years  we  have  had  no  opportunity  of  obseiT- 
ing  any  cases  of  pulmonary  syphilis.  Meanwhile  at  the  present 
time,  in  connection  with  the  discussion  in  our  lectures  of  chronic 
pulmonary  tuberculosis,  to  which  syphilis  predisposes  so  readily 
and  together  with  which  it  is  at  times  seen,  it  is  but  proper  to 
say  a  few  words  regarding  the  syphilitic  affection  of  the  lungs 
(pneumonia  syphilitica,  lues  pulmonum).  I  shall  make  use, 
for  this  purpose,  of  my  former  communications  and  of  the 
cases  observed  by  me  after  these  had  been  made. 

My  communications  were  made  at  the  meetings  of  the 
Moscow  Physio-Medical  Society,  April  11,  1877,  and  Janu- 
ary 16,  1878  (they  were  afterwards  published),  consequently 
several  years  before  the  discovery  by  Koch  of  the  tubercle 
bacillus  —  a  discovery  which  determined  the  specificity  of 
tuberculosis,  which  up  to  that  time,  under  the  influence  of 
Virchow's  theories  concerning  the  subject,  was  generally  con- 
sidered as  an  inflammatory  process  and  was  usually  known 
in  the  clinics  under  the  name  of  chronic  pneumonia.  The 
diagnosis  of  pulmonary  diseases  was  not  possessed  at  that  time 
of  such  an  important  means  as  the  detection  of  tuberculous 
bacilli  in  the  sputum.  This  notwithstanding,  the  above- 
mentioned  communications  preserved,  as  you  shall  see  from 
the  extracts,  their  clinical,  i.  e.  medico-practical  importance. 

From  the  First  Communication. 

Xot  every  physician  has  had  the  opportunity  to  observe 
an  uncomplicated,  positively  certain  syphilitic  affection  of  the 
lungs ;  but  who  has  not  heard,  or  does  not  hear  at  times  of 
certain  persons  affected  with  some  chest  disease,  who  were 
for  a  long  time  supposed  to  have  suffered  from  an  ordinary 
pulmonary  phthisis  and  were  treated  as  phthisical  persons,  but 
who  were  cured  finally  by  potassium  iodide  and  mercury  ? 
Excited  curiosity  will  naturally  search  for  the  determining 
differences  these  cases  present  as  compared  with  ordmary 
436 


—  437  — 

pulmonary  tuberculosis,  but  it  fails  to  obtain  any  definite 
indications.  Such  indications  are  absent  not  only  in  the 
literature  of  the  past,  but  even  in  that  of  very  recent  date. 

Ordinary  pulmonary  tuberculosis,  as  is  well  known,  is  often 
seen  in  syphilitic  patients.  Those  persons  who  had  been  in- 
fected by  syphilis  and  were  subjected  to  the  necessary  treat- 
ment therefor,  under  unfavorable  circumstances  usually  suffer 
from  a  radical  impairment  of  their  health,  which  frequently 
terminates  in  pulmonary  tuberculosis.  I  had  frequent  oc- 
casions to  observe,  that  not  only  persons  who  have  passed 
through  syphilis,  but  even  those  who  presented  its  early  or 
late  manifestations,  were  sufferers  from  pulmonary  tuberculosis 
in  its  ordinary  form,  presenting  febrile  symptoms,  haemoptysis, 
cough,  expectoration,  changes  in  the  percussion  sound,  in  the 
respiratory  murmur,  and  certainly  more  or  less  abundant  con- 
stantly present  rales.  In  such  cases  the  attempt  to  resort  to 
iodides  or  to  mercury  (if  the  syphilitic  manifestations  at  the 
time  present  required  it)  not  only  produced  an  improvement  in 
the  chest  trouble,  but  usually  tended  to  its  rapid  and  very 
pronounced  aggravation,  which  compelled  one  to  give  up 
the  specific  treatment. 

I  chanced  to  observe  two  cases  of  chest  troubles  in  syphilitic 
persons,  which  are  decidedly  different  from  those  I  have  just  out- 
lined. I  saw  the  first  case  fourteen  years  ago.  Patient,  thirty 
years  old,  of  a  good  constitution,  with  a  well-developed  chest, 
coming  from  a  family  of  healthy,  sturdily  built  people,  with  no 
case  of  tuberculosis  in  the  family,  and  living  among  favorable 
conditions  of  life,  had  been  suffering  durmg  the  last  six  or 
seven  years  with  attacks  of  undoubted  syphilitic  infection, 
manifested  for  the  last  three  years  by  deep  serpiginous  ulcers 
of  the  skin  and  periostitis  of  the  tibiae  and  ulnae,  which  yielded 
to  the  treatment  by  potassium  iodide,  and  reappeared  again 
after  the  cessation  of  the  treatment.  Several  weeks  before 
I  sa'w  the  patient  he  was  complaining  of  pain  and  a  feeling 
of  oppression  in  the  chest,  slight  dyspnoea  and  general  weak- 
ness ;  one  week  before,  thanks  to  an  accidental  cold,  he  began 
to  cough  slightly  and  became  somewhat  feverish.  (The  pa- 
tient became  during  the  last  years  very  susceptible  to  colds, 
and  his  attacks  of  colds  usually  take  the  form  of  a  febrile 
bronchitis  of  short  duration  and  slight  intensity).  During  the 
last  days  patient  was  confined  to  his  room,  the  cough  quieted 
down,  and  the  fever  disappeared  entirely. 

Status. —  Patient  is  costive,  his  abdomen  is  somewhat  dis- 


—  438  — 

tended  by  intestinal  gases,  the  urine  contains  neither  sugar 
nor  albumen ;  there  is  a  slight  cough,  some  expectoration 
(once  or  twice  in  the  morning ;  patient  always  fails  to  preserve 
it  for  physician's  examination),  dyspncea,  pain  and  a  feeling 
of  oppression  in  the  chest;  both  clavicles  are  very  prominent, 
the  sub-  and  supraclavicular  fossae  are  very  marked,  and  the 
sound  is  duller  in  these  places  (especially  on  the  right  side) 
than  in  the  area  below  ;  the  vocal  fremitus  is  weakened,'  while 
auscultation  gives  an  indefinite  respiratory  murmur,  approach- 
ing bronchial  respiration.  Everywhere  are  heard  non-abun- 
dant rales,  characteristic  of  bronchial  catarrh.  Patient  lost 
flesh.  His  sleep  is  poor.  He  has  slight  nocturnal  pains  in  the 
tibial  and  ulnar  bones. 

During  the  course  of  one  week  patient  was  confined  to  his 
room,  took  no  treatment,  and  observed  the  diet  prescribed  for 
him  in  view  of  the  meteorism  and  his  tendency  to  constipation. 
From  this  time  the  cough  and  expectoration  ceased  and  the 
rales  disappeared.  After  weighing  all  the  data  as  found  in  the 
case,  I  concluded  that  the  pulmonary  trouble  was  of  a  syphi- 
litic nature,  and  required  the  use  of  mercury,  because  during 
recent  years  the  patient  had  been  constantly  treated  by  potas- 
sium iodide  and  had  observed  that  it  failed  to  exert  the  same 
decided  action  it  had  done  formerly ;  moreover,  he  had  not  been 
treated  by  mercury  for  a  long  time,  and  generally  had  but  little 
mercurial  treatment.  Circumstances  compelled  me  to  adminis- 
ter the  mercurial  treatment  in  a  form  different  from  what  I 
usually  do.  During  the  fii'st  week  while  he  was  under  my 
observation,  before  I  commenced  the  mercurial  treatment, 
patient  began  to  suffer  from  severe,  intolerable  itching  which 
became  aggravated  at  night  and  prevented  his  sleep.  Scratch- 
ing caused  an  eruption  in  the  form  of  very  minute  red  papules, 
and  aggravated  the  itch ;  the  spots  that  the  patient  could  not 
reach  by  his  hands,  and  which  he  therefore  did  not  scratch, 
were  not  covered  by  the  eruption.  Baths  and  various  external 
applications  were  of  no  avail ;  only  applications  of  a  corrosive 
sublimate  solution  brought  considerable  relief.  In  view  of 
this  the  general  mercurial  treatment  was  ordered  as  follows  : 
externally  applications  of  a  solution  of  bichloride  for  the  itch- 
ing and  the  eruption,  and  also  certainly  for  its  internal  effect: 
as  the  eruption  was  widely  disseminated,  the  applications  of  the 
bichloride  solution  had  to  be  done  over  an  extensive  surface  ; 
internally  strong  Zittmann's  decoction  (Decoctum  Sarsaparillae 
Compositum  Fortius  P.  G.),  as  a  slight  laxative,  and  at  the 


—  439  — 

same  time  as  a  mercurial  preparation.  The  itching  and  the 
eruption  disappeared  rapidly ;  this  was|followed  by  a  return  of 
the  sleep,  and  after  four  weeks  of  such  treatment,  the  dyspnoea, 
pain  and  the  sensation  of  oppression  in  the  chest  passed  away. 
the  sub-  and  supraclavicular  fossae  became  less  marked,  for, 
thanks  to  the  improved  appetite  and  digestion,  the  patient 
grew  a  little  stouter,  while  the  above-described  symptoms 
which  had  been  elicited  by  palpation,  percussion  and  ausculta- 
tion, could  not  be  observed  again  :  the  chest  in  these  regions, 
as  everywhere  else,  presented  nothing  abnormal.  I  had  several 
occasions  to  run  across  the  patient  during  the  next  eight  years  : 
he  complained  somewhat  of  gastric  and  nervous  disturbances, 
but  his  chest,  outside  of  slight,  rapidly  passing  bronchitic 
troubles,  was  healthy. 

The  second  case,  which  I  had  under  observation  six  years 
ago  (during  the  winter  of  1870-71),  is  a  complete  duplicate  of 
the  foregoing  one.  Patient  was  also  thirty  years  old,  of  a  very 
robust  constitution,  living  under  favorable  conditions  ;  he  had 
been  suffering  from  syphilis  for  nine  years,  the  last  five  years 
principally  from  various  periostites  and  from  ozoena.  Was  once 
treated  with  mercury  at  the  beginning  of  the  disease,  but  since  this 
took  only  potassium  iodide,  which  has  ceased  recently  to  exert 
its  formerly  good  effect.  For  the  last  few  years  patient  began 
also  to  suffer  from  slight  disturbances  of  digestion  and  of  the 
nervous  system,  and  also  from  bronchitis  of  a  febrile  type  of  a 
slight  nature  and  rapidly  yielding  to  rest  at  home  and  the  use 
of  quinine.  For  some  time  before  I  saw  the  patient  first,  he 
was  taken  sick  with  his  usual  febrile  bronchitis,  but  this  time 
it  was  accompanied  by  pain  in  the  chest,  and  by  dyspnea ;  these 
were  not  present  formerly.  Patient  confined  himself  within, 
the  house,  and  when  I  was  called  to  see  him  for  the  fu'st  time 
he  had  no  fever,  and  the  cough  was  just  passing  away. 

Status.  —  Patient  has  a  slight  cough  without  expectoration  ; 
dyspnoea,  a  feeling  of  oppression  and  pain  in  the  chest ;  the 
clavicles  are  very  prominent,  and  the  sub-  and  supraclavicular 
fossae  are  sharply  marked,  especiallj-  on  the  right  side :  over 
these  places  the  sound  is  duller  and  the  vocal  fremitus  weaker 
than  in  the  area  below,  especially  on  the  right  side,  while  the 
respiratory  murmur  is  of  an  indefinite  quality,  approaching 
bronchial  respiration ;  over  the  whole  chest  there  are  heard  rales 
here  and  there,  peculiar  to  bronchial  catarrh  ;  there  is  no  fever, 
patient  became  somewhat  emaciated.  As  in  the  first  case,  pa- 
tient was  given  no   treatment  during  the  first  week:  for  the 


—  440  — 

same  reasons  as  guided  me  in  the  first  case,  I  wanted  to  examine 
the  disease  more  thoroughly,  before  prescribing  specific  treat- 
ment in  the  presence  of  such  chest  symptoms  ;  during  this  time 
the  cough  disappeared  entirely,  as  well  as  the  rales,  while  the 
other  symptoms  remained  unchanged.  Guided  by  the  same 
reasons  as  in  the  first  case,  mercurial  treatment  was  ordered,  in 
the  form  of  inunctions  with  mercurial  ointment.  Altogether 
twenty-five  inunctions  were  made  :  five  of  ten  grains  each,  five 
of  fifteen  grains,  and  fifteen  of  twenty  grains  each.  During  the 
course  of  the  treatment  the  morbid  symptoms  began  to  disappear, 
and  at  the  termination  of  the  same  there  was  neither  dyspnoea 
nor  any  feeling  of  oppression  or  pains  in  the  chest ;  the  above- 
described  symptoms,  which  were  observed  on  the  objective  ex- 
amination of  the  chest  have  also  disappeared,  the  sub-  and 
supraclavicular  fossa  became  much  less  prominent,  partly,  of 
course,  on  account  of  the  fact  that,  thanks  to  the  corrected  diet, 
the  appetite  and  the  digestion  were  in  good  order  during  the 
treatment,  and  the  patient  grew  somewhat  stout. 

The  first  case  impressed  me,  not  because  the  chest  symptoms 
which  could  excite  a  suspicion  of  pulmonary  tuberculosis,  yielded 
so  completely  to  the  effects  of  the  mercurial  treatment,  but  be- 
cause the  whole  group  of  these  symptoms  presented  such  a  sharp 
distinction  from  the  collection  of  symptoms  of  ordinary  pul- 
monary phthisis,  and  the  patient  himself  resembled  a  consump- 
tive so  little ;  it  was  only  the  second  observation,  in  which  all 
the  characteristics  of  the  first  case  were  repeated  with  photo- 
graphic accuracy,  which  led  me  to  the  conclusion  that  I  had  to 
deal  not  with  a  group  of  coincidently  connected  symptoms,  but 
with  a  permanent  form  of  syphilitic  pneumonia,  in  its  genuine, 
uncomplicated  form  ;  a  diseased  condition,  which  semiotically 
and  diagiiostically  differs  greatly  from  the  picture  of  ordi- 
nary pulmonary  tuberculosis  in  non-syphilitics,  as  well  as  in 
syphilitics.  The  principal  criterion  by  which  we  could  judge 
that  in  both  cases  the  affection  was  undoubtedly  of  a  syphilitic 
nature,  the  criterion  ex  juvantibus  was  but  too  apparent :  under 
the  influence  of  the  mercurial  treatment  the  morbid  phenomena 
disappeared.  My  conviction  was  even  more  strengthened  by 
all  we  know  concerning  the  anatomical  alterations  in  the  pul- 
monary tissue  when  it  becomes  aft'ected  by  syphilis,  the  inter- 
stitial and  gummatous  character  of  these  alterations  which 
result  in  the  thickening  of  the  pulmonary  tissue,  and  in  the  ex- 
pulsion of  air  therefrom  —  all  of  which  coincided  so  fully  with 
the  nature  of  the  symptoms  observed  in  the  above-described 
cases  on  their  objective  examination. 


—  441  — 

Putting  now  together  the  peculiarities  of  these  cases  which 
enable  us  to  recognize  syphilitic  pneumonia  in  its  pure,  uncom- 
plicated form,  as  distinguished  from  chronic  pulmonary  tuber- 
culosis seen  in  non-syphilitic  patients,  as  well  as  in  syphilitics, 
we  get  the  following: 

1.  Anamnestic  and  other  data,  pointing  to  an  affection  of  the 
patient's  organism  by  syphilis. 

2.  The  robust  constitution  of  the  patient.  It  is  very  likely 
that  persons  with  weak  constitutions  and  with  a  predisposition 
to  ordinary  —  tuberculous  —  consumption,  are  rather  sooner  af- 
fected by  the  disease,  their  lives  not  being  prolonged  until  the 
appearance  of  late  syphilitic  manifestations,  to  which  belongs 
syphilitic  pneumonia. 

3.  The  objective  symptoms  of  thickening  of  the  lungs  are  as 
follows  :  dull  percussion  sound,  weakened  vocal  fremitus,  alter- 
ation in  the  normal  respiratory  mui'mur.  A  sharp  marking  out 
of  the  sub-  and  supra-clavicular  fossae,  due  very  likely  to  an 
adhesive  pleurisy,  which  accompanies  syphilitic  pneumonia  as 
frequently  as  adhesive  perihepatitis  accompanies  syphilitic  he- 
patitis. Dyspnoea,  a  feelhig  of  oppression  and  pain  in  the 
chest. 

4.  Absence  of  haemoptysis,  cough,  expectoration  and  rales. 

5.  Absence  of  febrile  condition. 

6.  The  decided  effect  of  the  specific  treatment. 

That  such  cases  of  syphilitic  pneumonia  as  described  above 
may  in  their  further  course,  if  not  recognized  and  treated  at  the 
beginning,  or  if  not  presenting  any  possibility  for  treatment  un- 
der given  conditions,  become  complicated  by  other  affections  of 
the  respiratory  organs,  such  as  a  severe  bronchitis,  a  pleurisy 
with  effusion,  an  acute  and  chronic  pneumonia  of  non-syphilitic 
nature,  and  then  appear  in  another  form,  is  both  possible  and 
probable ;  but  such  complicated  cases  do  not  permit  a  deduction 
to  be  drawn  therefrom  in  regard  to  the  diagnostic,  prognostic, 
and  therapeutic  conclusions  about  syphilis  of  the  lungs. 

FRo:\r  THE  Second  Cojvoiijnicatiox. 

Patient,  thirty-two  years  old,  entered  the  facult}^  clinic  Octo- 
ber 21,  1877,  complaining  of  dyspncea,  cough,  loss  of  voice, 
swelling  of  the  legs,  and  enlargement  of  the  abdomen. 

Mode  of  living  and  anamnesis.  —  Patient  lives  in  a  damp  lo- 
cality. Residence  and  board  good.  He  was  addicted. to  much 
smoking,  and  to  immoderate  whiskey  drinking  (neither  smoked 


—  442  — 

nor  drank  lately),  and  being  a  superintendent  of  an  estate,  he 
talked  much  and  loudly,  and  fatigued  himself. 

Patient  comes  from  a  healthy  family.  In  February,  1870 
(when  twenty-live  years  old),  he  had  post-coitum  ulcera  penis, 
which  passed  away  in  the  course  of  two  months  and  a  half  with 
the  aid  of  local  treatment  solely.  In  November  of  the  same 
year  there  appeared  a  papular  eruption,  and  later  on  ulcers  on 
the  skin.  With  the  aid  of  thirty  inunctions  with  mercurial 
ointment,  and  eight  bottles  of  potassium  iodide,  everything  dis- 
appeared by  February,  1871. 

During  March,  1872,  there  appeared  nocturnal  pains  and 
slight  swellings  of  the  clavicles  and  of  the  tibiae ;  these  lasted 
for  eight  months  and  disappeared  without  treatment.  During 
the  next  four  years  our  patient  enjoyed  good  health.  In  March, 
1877,  there  appeared  a  cough  with  dyspnoea  and  expectoration; 
during  June  various  oedemata  and  general  weakness  ;  in  July, 
hoarseness  of  the  voice  and  pain  on  deglutition.  Later  on,  by 
the  time  he  entered  the  clinic,  all  the  enumerated  symptoms  in- 
creased rapidly,  with  the  exception  of  the  cough  which  dimin- 
ished during  summer  and  remained  so  (since  autumn  the  patient 
was  conhned  within  doors)  ;  there  were  but  trifling  febrile  symp- 
toms, if  we  are  to  judge  from  the  inquiry. 

Status.  —  The  appetite  is  poor,  there  are  slight  dyspeptic 
phenomena ;  diarrhoea ;  ascites.  The  liver  and  spleen  do  not 
admit  of  palpation.  The  urine  is  600  c.c.  in  quantity  during 
twenty-four  hours ;  it  is  reddish,  turbid,  and  contains  much  al- 
bumen and  many  cylinders. 

There  is  pain  in  the  throat  on  swallowing  and  coughing  ; 
complete  aphonia :  laryngoscopic  examination  shows  a  condi- 
tion of  thickening  and  softening  of  the  mucous  membrane  of 
the  true  and  false  vocal  cords  and  of  the  epiglottis,  and  later 
on  also  the  presence  of  ulcers  in  these  parts.  There  is  severe 
dyspnoea  ;  the  cough  is  but  slight,  expectoration  of  a  muco- 
purulent character,  with  an  admixture  of  blood,  the  quantity  of 
the  expectoration  at  the  beginning  Ijeing  about  one-fourth  of  a 
glassful  for  twenty-four  hours  ;  later  on  the  quantity  of  expec- 
toration and  the  cough  became  very  insignificant.  On  the  right 
side  the  sound  is  dull  over  the  clavicle  and  from  there  down  to 
the  third  rib ;  thence  downward  it  grows  clearer ;  in  the  subscap- 
ular fossa  and  also  between  the  scapula  and  the  vertebral  column 
upward,  the  sound  is  also  dull.  On  the  left  side,  immediately 
above  and  below  the  clavicle,  the  sound  is  somewhat  dull,  but 
excepting  these  regions  it  is  everywhere  clear.     All  over  the 


—  443  — 

lungs  there  are  heard  whistling  rales ;  besides  these,  in  the  area 
of  the  dull  sound  on  the  right  side,  there  is  heard  a  respira- 
tory murmur  approaching  bronchial  respiration,  and  very  few 
loud  moist  rales  ;  on  the  right  side  prolonged  expiration.  —  The 
impulse  of  the  heart  is  not  displaced,  but  it  is  weak :  its  tones 
are  clear. 

The  pulse  is  96,  somewhat  weak.  The  evening  temperature 
reaches  38°  B,  (100.4°  F.).  There  is  everywhere  a  slight 
anasarca,  which  is  considerable  on  the  foot  and  the  leg.  The 
skin  presents  traces  of  serpiginous  ulcers.  The  sleep  is  poor. 
There  is  general  debility. 

The  course  of  the  disease.  —  Durmg  the  first  days  the  patient 
was  given  Dover's  powder  and  some  quinine.  The  cough  rap- 
idly diminished  after  this,  and  so  did  the  quantit}"  of  expectora- 
tion and  the  number  of  rales ;  but  the  diarrhoea  increased  some- 
what, and  quinine  was  therefore  put  aside,  and  tra.  opii  simplex 
was  given.  A  week  after  the  patient's  admission  to  the  clinic 
the  fever  began  to  increase  somewhat,  the  pulse  grew  weak, 
notwithstanding  the  use  of  stimulants  (as  wine  and  tra. 
valer.  aether.),  the  dropsical  phenomena  became  more  marked, 
and  there  appeared  uraemic  symptoms  :  heaviness  and  pain  in 
thef  head,  and  nausea.  November  8th  there  appeared  erysipelas 
accompanied  by  considerable  fever  (39.7°  M.  —  103.6°  ^.),  and 
November  12th  patient  died.  Durmg  all  the  time  that  the  pa- 
tient remained  in  the  clinic,  the  area  of  the  dull  sound  over  the 
surface  of  the  chest  increased  gradually  from  above  do^vnward ; 
during  the  last  days  it  was  impossible  to  examine  the  chest  pos- 
teriorly on  account  of  the  patient's  extreme  debility. 

The  patient  was  under  the  observation  of  our  clmical  assis- 
tant, Dr.  V.  G.  Nesteroff.  The  first  communication  made  by 
me  in  regard  to  syphilitic  pneumonia  led  him  to  think  of  the 
possible  presence  of  such  in  the  present  case,  in  view  of  the  fact 
that  the  symptoms  of  thickenmg  of  the  lungs,  and  especially  of 
the  right  one,  were  so  considerable,  while  the  fever  was  slight 
and  moist  rales  were  observed  only  over  a  very  limited  area 
(under  the  right  clavicle),  while  the  whistling  ones  disappeared 
during  the  first  week  of  the  patient's  sojourn  in  the  clinic. 

While  analyzing  the  case  before  my  students,  I  arrived  at 
the  following  diagnostic  conclusions  :  1.  Chronic  inflammation 
of  the  kidneys  (large  kidney,  i.  e.  chronic  parenchymatous  ne- 
phritis). 2.  The  ascites  and  the  diarrhoea  may  possibly  have 
their  special  causation  in  an  alcoholic  or  syphilitic  cirrhosis  of 
the  liver.  3.  A  simple  or  degenerative  atrophy  of  the  heart.  4.  As 


^  444  — 

regards  the  pulmonary  affection,  I  agreed  with  Dr.  Nesteroff 
that  the  peculiarities  of  the  case,  as  observed  by  him,  together 
with  the  anamnestic  data,  and  the  nature  of  the  laryngeal 
changes,  lead  us  to  recognize  in  the  present  case  a  syphilitic 
pneumonia ;  but  as  fever,  haemoptysis,  cough,  expectoration, 
and  moist  rales,  although  observed  in  a  small  degree,  are  still 
not  entirely  absent,  as  was  the  case  with  the  patients  who  suf- 
fered from  a  pure  syphilitic  affection  of  the  lungs,  and  who  were 
spoken  of  in  my  first  communication,  we  may  then  assume  that 
the  present  case  presents  neither  a  pure  syphilitic  pneumonia, 
nor  a  pure  ordinarj^  chronic  one  (the  usual  pulmonary  consump- 
tion), but  very  possibly  a  contemporaneous  affection  of  the 
lungs  by  both  processes.  As  regards  treatment,  the  specific  — - 
antisyphilitic  —  treatment  was  contraindicated  by  the  multitude 
of  painful  affections,  and  by  the  extreme  failure  of  nutrition 
and  strength,  as  well  as  by  the  fact  that  the  syphilitic  affection 
of  the  lungs  was  not  pure,  but  complicated  by  phenomena  of 
ordinary  consumption. 

The  autopsy  was  performed  by  the  then  decent  of  pathologi- 
cal anatomy  (now  professor  of  general  pathology),  A.  B.  Vogt. 
The  results  of  an  extensive  report  and  of  the  microscopical  ex- 
amination are  as  follows  :  syphilitic  disease  of  the  larynx  (ulcers, 
scars,  diffuse  papillary  growths),  agglutinated  pleura,  syphilitic 
(interstitial  and  gummatous)  affection  of  the  upper  lobes  of  both 
lungs  (especially  of  the  right  one),  a  chronic  catarrhal  pneumo- 
nia also  of  the  right  lung  (of  its  upper  and  middle  lobes),  an 
acute,  developed  during  the  last  days  of  patient's  life,  catarrhal 
inflammation  of  the  lower  portions  of  both  lungs,  "  brown  " 
atrophy  (atrophia  fusca^  of  the  cardiac  muscle  (the  cardiac 
valves  and  orifices  are  not  altered)  ;  a  syphilitic  interstitial  he- 
patitis, amyloid  degeneration  of  the  spleen ;  the  increased  size  of 
the  kidneys  presents  sharply  defined  signs  of  Bright's  disease. 

While  communicating  this  case  at  the  annual  (January,  1878) 
meeting  of  the  Physio-Medical  Society,  I  arrived  at  the  follow- 
ing conclusions  :  1.  What  I  alluded  to  in  my  first  communi- 
cation of  April,  1877,  as  possible  and  probable,  became  a  real 
fact  in  this  case  :  namely,  the  syphilitic  pneumonia  was  proved 
to  have  become  complicated  by  bronchitis,  adhesive  pleurisy  and 
by  chronic  catarrhal  pneumonia,"*  as  well  as  by  acute.  2.  This 
case  proves  that  it  is  possible  to  diagnose  not  only  a  pure  syph- 
ilitic pneumonia,  but  a  complicated  one  as  well. 

*  Sucli  was  the  name  at  that  time,  under  the  influence  of  Virchow's 
teaching,  of  chronic  pulmonary  tuberculosis. 


—  445  — 

Observations  made  by  me  in  the  domain  of  diseases  of  the 
respiratory  organs,  and  especially  of  syphilis  and  pulmonar}^ 
tuberculosis,  during  the  last  fifteen  years  —  since  my  second 
communication  on  syphilis  pulmonum  —  strengthen  my  asser- 
tions which  were  put  forward  by  me  in  the  above  communica- 
tions, touching  upon  the  semiotics  and  the  diagnosis  of  simple 
and  complicated  syphilitic  pneumonia.  As  what  concerns 
the  treatment  of  this  last  I  must  make  a  correction.  In  the 
above  communications  I  spoke  against  specific  treatment  in 
syphilitic  pneumonia  complicated  by  tuberculosis,  in  view  of 
the  fact,  that  during  such  a  treatment  this  last  is  liable  to 
rapid  advances.  For  the  immense  majority  of  such  cases  this 
position  holds  good  even  now.  But  with  the  aid  of  modern 
diagnosis  (as  the  presence  of  tuberculous  bacilli  in  the  sputum 
enables  one  at  times  to  recognize  early  even  very  slightly  diffused 
affections  of  the  lungs  by  tuberculosis,  and  consequently  early 
measures  of  treatment  can  be  adopted  in  time),  and  modern 
treatment,  such  as  by  creosote  in  large  doses,  there  occur, 
although  rarely,  exceptions,  as  a  type  of  which  may  serve  this 
case  observed  by  me. 

,The  patient,  who  became  infected  with  syphilis  about  ten 
years  ago  and  who  presented  at  the  time  seen  undoubted 
manifestations  of  syphilis  of  the  nervous  system,  begins  to 
cough  more  frequently  than  formerly  (he  usually  coughs 
because  of  a  laryngeal  catarrh  brought  on  by  smoking),  and 
complains  of  pain  in  the  side  of  the  chest ;  at  the  same  time  he 
grows  somewhat  thin  and  weak,  but  has  no  febrile  symptoms. 
Objective  investigation  shows  considerable  solidification  in  the 
upper  lobe  of  the  right  lung,  and  with  this  there  is  heard  over 
the  solidified  area  a  respiratory  murmur  of  a  character  ap- 
proaching bronchial  respiration,  and  at  times  infrequent,  non- 
abundant  rales ;  the  expectoration,  which  is  very  scanty,  shows 
the  presence  of  tuberculous  bacilli.  Thanks  to  a  sufficiently 
thorough  iodide  treatment  the  symptoms  of  solidification  and 
pain  in  the  right  side  disappeared,  while  the  patient  himself 
grew  stronger;  with  the  aid  of  creosote  following  this  treat- 
ment, the  cough  diminished  to  the  degree  usual  with  the 
patient,  the  rales,  as  well  as  the  bacilli  in  the  expectoration, 
disappeared,  while  the  patient  himself  became  so  stout  and 
strong,  that  his  health  could  be  called  florid.  Later  on  the 
patient  underwent  also  calomel  and  iodide  treatment,  which 
was  ordered  because  of  the  other  above-mentioned  manifesta- 
tions of  syphilis,  without  any  marked  impairment  of  his  health 
and  without  the  slightest  symptoms  of  a  recurrence  of  the 
pulmonary  tuberculosis. 


SYPHILIS  OF  THE  HEART. 

Feom  the  Clln'ical  Sta2>:dpoi^"t. 


The  short  report  of  my  address  *  which  was  published  in  the 
Contributions  to  the  Pliysio-Medical  Society  (No.  1,  January, 
1887)  contains  only  my  conclusions  ;  the  remaining  part  of 
the  report  is  not  written  by  me  and  it,  as  well  as  the  references 
which  appeared  in  many  other  editions,  present  certain  inaccu- 
racies due  to  somewhat  .hurried  observations. 

Having  some  time  at  mj^  disposal  during  the  summer  of 
1889,  I  decided  to  prepare  for  publication  also  my  own  com- 
munication on  syphilis  of  the  heart,  as  I  can  see  from  medical 
literature  that  the  subject  is  just  as  interesting  now  as  it  was 
two  and  a  half  years  ago ;  but  this  communication  appears 
at  the  present  time  in  a  somewhat  changed  form :  first,  be- 
cause the  number  of  cases  observed  by  me  has  increased,  and 
one  of  these,  which  had  been  under  my  care  in  the  clinic  during 
the  last  spring,  will  be  discussed  by  me  later  on,  as  it  presents 
some  peculiar  characteristics  ;  and  secondly,  because  I  wil]  only 
touch  slightly  on  the  general  therapy  of  the  diseases  of  the 
heart  (to  this  I  had  to  resort  in  complicated  cases  of  cardiac 
syphilis  ;  I  therefore  spoke  of  it  in  particular  during  my  first 
communication),  as  I  intend  to  take  up  the  subject  and  discuss 
it  more  fully  in  the  edition  of  my  lectures  when  treating  of  the 
subject  of  diseases  of  the  heart  in  general. 

Turning  to  the  literature  on  the  pathology  of  the  subject.  I 
must  say  that  with  the  exception  of  some  additional  matter  of  a 
casuistic  nature,  the  subject  under  discussion  did  not  advance 
during  these  two  years  and  a  half. 

As  regards  the  pathological  anatomy,  we  have  long  been 
informed  of  the  existence  of  gummatous  myocarditis,  and  we 
know  now  of  syphilitic  affections  of  both  the  endocardium 
and  pericardium ;    but  we  posses.s  no  definite  mformation  re- 

*  Delivered  at  the  annual  meeting  of  the  Moscow  Physio-Medical 
Society,  January,  1887. 

446 


—  447  — 

garding  syphilitic  affections  of  the  cardiac  vessels  and  nerves, 
and  meanwhile  clinical  observations,  as  we  shall  see  later,  lead 
us  to  the  conclusions,  that  in  some  cases  the  syphilitic  process 
attacks  the  cardiac  nerves  even  to  a  preeminent  degree  as  com- 
pared with  the  other  tissues  of  the  organ.  As  far  as  the  clmi- 
cal  data  are  concerned,  the  modern  text-books  of  special  pathol- 
ogy and  therapeutics  do  not  pay  due  attention  to  syphilis  of 
the  heart.  To  be  sure,  among  the  causative  agencies  of  cardiac 
diseases  syphilis  is  mentioned  as  one  ;  gummatous  myocarditis 
is  treated  of  by  pathological  anatomy ;  but  there  is  no  mention 
made  of  cardiac  syphilis  in  either  symptomatology  or  diagnosis  ; 
while  in  discussing  the  treatment  some  allude  to  the  possibility  of 
a  specific  treatment  in  cardiac  diseases,  while  others  do  not 
mention  even  this.  Thus  the  study  of  the  modern  text-books 
will  rather  tend  to  cultivate  a  neglect  toward  the  subject  of  car- 
diac syphilis,  failing  to  bestow  on  it  the  attention  it  merits. 
An  impression  is  abroad  that  syphilis  is  but  an  accidental  dis- 
covery during  autopsies,  and  that  it  is  rather  a  subject  for  path- 
ological anatomy  than  for  the  clinic.  Be  as  it  may,  the  study 
of  these  text-books  fails  to  convey  the  idea  of  the  considerable 
practical  importance  of  this  affection.  In  vain  will  the  student 
search  in  these  text-books  for  answers  to  the  questions :  What 
is  the  clinical  aspect  of  syphilis  of  the  heart  ?  In  what  forms 
does  it  present  itself  ?  Has  this  cardiac  affection  any  practical 
significance  so  that  it  can  be  recognized  in  time  and  subjected 
to  successful  treatment?  How  effective  may  such  treatment 
prove  ? 

Up  to  the  present  time  I  have  had  occasion  to  observe  already 
more  than  ten  cases.  I  will  first  describe  those  which  present 
a  smaller  variety  of  attacks  and  are  less  complicated  by  other 
diseases. 

The  First  Case.  —  Patient  is  about  forty  years  old,  was  infected 
with  syphilis,  and  does  not  abuse  alcoholic  drinks.  For  the  last 
few  years  he  has  been  suffering  with  dyspnoea,  palpitation,  and 
at  times  with  symptoms  of  disturbed  circulation  (as  evinced  by 
(jedema  of  the  legs  and  lungs  and  by  enlargement  of  the  liver), 
which  is  but  slightly  and  for  a  short  time  relieved  by  digitalis. 
The  left  ventricle  is  enlarged,  but  the  heart  sounds  are  clear  and 
there  are  no  symptoms  of  atheromatosis  of  the  arteries:  i.  e. 
not  only  is  there  no  systolic  murmur  at  the  sternum,  but  the 
arteries  are  not  stiff,  and  there  are  no  symptoms  of  a  disturbed 
cerebal  circulation.  The  kidneys  are  healthy.  Treatment  by 
sodium  iodide,  commencing  with  ten  and  increasing  up  to  100 


—  448  — 

grains  per  day  during  the  period  of  six  weeks,  brought  about  a 
complete  improvement  in  the  patient's  condition:  all  the  morbid 
■symptoms  disappeared,  and  in  the  three  or  four  years  during 
which  the  patient  was  constantly  under  my  observation,  he  only 
had  at  times  attacks  of  dyspnoea  and  palpitation  of  much  less 
frequent  occurrence  and  of  slighter  intensity  than  formerly, 
which  yielded  rapidly  to  digitalis  ;  but  he  never  again  had 
any  oedema.  The  left  ventricle  diminished  in  size  (the  apex 
beat  of  the  heart  is  on  the  left  mammillarj^  line,  whereas  for- 
merly it  reached  beyond  it)  and  the  pulse  became  less  frequent, 
stronger  and  more  regular. 

jSTutrition  and  strength  improved  considerably.  Patient  re- 
peated twice  the  treatment  with  sodium  iodide. 

The  seeojid  case  is  in  all  respects  similar  to  the  foregoing,  ex- 
cept that  the  patient  suffered,  not  from  a  disturbance  of  the 
general  circulation,  but  from  frequent  attacks  of  cardiac  asthma 
which  culminated  in  oedema  of  the  lungs  and  did  not  yield  to 
either  digitalis  or  to  any  other  remedies.  After  a  course  of 
energetic  treatment  with  sodium  iodide,  the  attacks  disappeared 
entirely  for  a  long  time,  and  even  when  they  reappeared  later  on 
they  were  much  less  frequent  and  of  slighter  intensity,  and 
yielded  rapidly  to  digitalis. 

Third  Case.  ■ —  Patient  is  fifty-five  years  old;  is  infected 
with  syphilis ;  suffered  before  with  acute  articular  rheumatism, 
and  abused  to  some  extent  alcoholic  drinks.  Has  been  suffer- 
ing for  more  than  a  year  with  torturing  attacks  of  angina  pec- 
toris, for  which  he  took  a  great  variety  of  palliative  remedies, 
lately  always  nitro-giycerine,  several  times  a  day,  with  but  a 
trifling,  rapidly  passing,  relief.  Patient  has  stiff  arteries  and 
presents  evident  symptoms  of  insufticiency  of  the  aortic  valves 
(sharp  diastolic  murmur  at  the  sternum,  a  jerking  pulse,  enlarge- 
ment of  the  left  ventricle);  but  outside  of  the  attacks  of  angina 
pectoris  he  presents  nothing  morbid :  neither  dyspncea,  nor  pal- 
pitation, nor  any  oedema,  —  all  the  functions  are  normal.  The 
sodium  iodide  treatment  relieved  the  patient  considerably  and 
later  on  inunctions  of  mercurial  ointment  brought  about  a  com- 
plete cessation  of  the  attacks  of  angina  pectoris  ;  the  objective 
signs  of  insufficiency  of  the  aortic  valves  and  of  general  chronic 
arteritis  remained  unchanged. 

The  fourth  case  is  similar  to  the  third :  there  were  also  at- 
tacks of  angina  pectoris,  which  yielded  to  specific  treatment. 

The  above-described  cases  of  syphilis  of  the  heart  must  be 
considered,  from  their  aspects,  as  exceptions,  because  the  other 


—  449  — 

cases,  i.  e.  the  considerable  majority  of  such,  present  usually 
another  aspect,  differing  by  a  great  variety  of  attacks,  and  by 
being  usually  considerably  complicated,  namely :  by  alcoholism 
or  gout,  by  chronic  arteritis,  gastro-intestinal  disturbances,  and 
also  by  simultaneous  syphilitic  affections  of  other  organs,  most 
frequently  of  the  nervous  system  and  of  the  liver.  The  cardiac 
symptoms  in  such  cases,  as  I  said  above,  take  on  a  great  variety 
of  forms  and  are  usually  all  easily  discoverable :  such  as  a  con- 
stant dyspnoea  with  palpitation  and  a  sensation  of  oppression 
in  the  region  of  the  heart,  attacks  of  cardiac  asthma,  as  well  as 
of  angina  pectoris,  considerable  cedema  and  accumulations  in 
the  cavities  as  a  result  of  disturbed  circulation.  The  heart  is 
usually  enlarged,  especially  its  left  ventricle,  and  the  pulse  is 
weak,  frequent  and  arythmical;  a  systolic  murmur  is  frequently 
heard  at  the  sternum.  Examination  of  both  the  present  and 
the  past  conditions  of  the  patient  either  elicits  syphilitic  infec- 
tion directly,  or  makes  it  very  probable. 

The  general  character  of  all  these  cases  is  such  that  the 
most  careful  and  conscientious  non-spe.cijic  treatment  fails  to 
bring  about  any  marked  improvement,  while  a  specific  treat- 
rnent  consisting  of  the  employment  of  sodium  iodide  and  of 
mercurial  inunctions  results  in  a  lasting  improvement :  the  mor- 
bid phenomena  disappear,  there  remain  only  the  objective  signs 
of  some  enlargement  of  the  heart,  and  at  times  a  weak  systolic 
murmur  over  the  sternum. 

As  a  type  of  the  above  alluded  to  majority  of  cases  of  car- 
diac syphilis  as  seen  by  me,  I  will  now  describe  more  fully  the 
one  spoken  of  before,  which  was  under  my  observation  in  the 
clinic  during  the  last  spring,  and  served  as  a  subject  for  my 
clinical  lectures  during  the  beginning,  the  middle  and  the  end 
of  the  patient's  sojourn  in  the  clinic. 

Patient,  thirty-four  years  old,  entered  the  clinic  March  7, 
1889,  in  a  very  aggravated  condition,  complaining  of  extreme 
weakness,  dyspnoea,  and  swelling  of  the  whole  body,  and  espe- 
cially of  the  legs. 

Mode  of  life  and  anamnesis. —  Patient  has  no  constant  place 
of  residence,  but  lives  in  turn  in  three  different  cities,  several 
months  in  each.  His  rooms,  in  a  hotel,  are  not  always  satis- 
factory ;  the  watercloset  is  always  cold.  Patient  drinks  some 
four  glasses  of  tea  per  day ;  avoids  drmking  coffee,  as  it  gives 
rise  to  palpitation  ;  has  one  meal  a  day,  always  containing  some 
meat;  smokes  much,  and  is  addicted  to  alcoholic  drinks  :  not 
less  than  seven  wine-glasses  of  brandy,  and  seven  bottles  of  beer 


—  450  — 

per  day ;  and  three  times  a  month  even  more  than  this.  With 
■  the  exception  of  the  last  month,  such  drinking  has  continued 
for  ten  years,  but  during  the  last  month  he  entirely  discon- 
tinued the  use  of  alcoholic  drinks  ;  his  occupation  is  not  of  a 
fatiguing  nature,  outside  of  considerable  travel  —  in  winter  on 
sleds,  in  summer  mostly  on  the  steamer. 

The  patient  is  tall  and  broadly  built ;  was  even  when  young 
inclined  to  corpulence  and  was  subject  to  attacks  of  slight 
dyspnoea,  but  since  he  began  to  abuse  alcoholic  drinks  both  the 
corpulence  and  dyspncjea  increased ;  barring  this,  the  patient 
does  not  recollect  having  had  any  diseases  until  two  years  ago. 
At  that  time  he  became  infected  with  syphilis  :  there  appeared 
an  ulcer  on  the  penis,  eruptions,  and  falling  out  of  the  hair. 
Patient  took  pills  of  mercury  during  three  months,  and  after 
a  two  months'  interval,  for  another  month  and  a  half ;  as  a  re- 
sult all  the  above-named  symptoms  of  syphilis  disappeared,  but 
the  patient  began  to  feel  weak  and  fatigued  by  his  work,  which 
he  formerly  bore  well.  Some  eight  months  ago,  after  an  ordinary 
day's  work,  he  had  at  night  an  attack  of  angina  pectoris  without 
any  ascribable  cause  :  there  was  pain  along  the  sternum  and 
in  the  region  of  the  heart  transmitted  to  the  back,  left  shoulder, 
and  the  left  arm  down  to  the  elbow  ;  the  pain  was  not  severe, 
but  lasted  for  a  whole  night  and  passed  away  in  the  morning 
without  any  treatment.  Since  then  there  occurred  nocturnal 
pains  in  the  legs,  in  the  region  of  the  tibial  bones.  Patient 
again  took  pills  of  mercury  during  one  month,  and  the  pains  in 
the  legs  disappeared. 

The  second  attack  of  angina  pectoris  similar  to  the  first  one 
took  place  on  the  night  of  February  1,  1889;  it  was  not  severe, 
but  also  continued  during  the  whole  night,  for  about  eight 
hours.  Patient  at  once  left  off  drinking  brandy  and  beer,  after 
which  he  rapidly  lost  his  appetite  and  grew  thin  and  weak. 
Three  weeks  ago  the  dyspnoea  began  to  increase,  and  there  ap- 
peared oedema  of  the  legs.  Patient  took  no  treatment,  and  the 
described  attacks,  having  reached  the  above-mentioned  severe 
state,  compelled  him  to  enter  our  clinic. 

Status  March  7',  1889,  —  Appetite  not  as  good  as  it  was  before  ; 
eating  is  accompanied  by  pyrosis,  eructations,  nausea,  and  oc- 
casional vomiting.  Since  the  patient  gave  up  drinking  beer 
and  brandy  he  suffers  from  constipation  ;  has  every  other  day 
some  hard  evacuations.  Until  that  time  he  used  to  have  three 
to  four  soft,  gruel-like,  painless  stools.  The  urine  is  secreted 
freely,  to  the  amount  of  1,000  c.c.  in  twenty-four  hours,  of  a  red 


—  451  — 

color,  containing  neither  albumen  nor  sugar.  The  liver  is  en- 
larged and  painful.  The  spleen  presents  nothing  abnormal. 
There  are  symptoms  of  fluid  accumulations  in  the  abdominal 
cavity,  and,  as  mentioned  above,  considerable  Oidema  of  the  arms, 
legs,  and  of  the  entire  subcutaneous  tissue.  Patient  complains 
of  palpitation.  On  account  of  the  present  corpulence,  of  the 
cedema  of  the  subcutaneous  tissue,  and  of  the  weak  cardiac  ac- 
tivity, the  results  obtained  by  the  objective  examination  of  this 
last  are  not  pronounced:  there  is  a  weak  cardiac  impulse  felt  at 
the  left  mammillar}^  line,  but  percussion  elicits  a  dull  sound  over 
the  left  half  of  the  sternum,  and  auscultation  a  weak  systo- 
lic murmur.  The  pulse  is  120,  verj^  weak  and  arythmical. 
The  dyspn(jea  is  very  pronounced,  46  to  52  per  minute;  patient 
is  unable  to  lie  down.  There  is  no  cough.  The  condition  of 
the  lungs,  as  shown  by  percussion,  is  normal  (onl}^  the  dia- 
phragm is  somewhat  raised),  and  auscultation  shows  abundant 
moist  rales  under  both  scapulee.  The  temperature  is  38°  R. 
(98.4°  _F.).  He  hardly  sleeps  at  all  on  account  of  the 
dyspncjea.  His  mental  state  is  extremely  depressed,  and  at 
times  very  irritable.  There  is  considerable  weakening  of  the 
memory.  Xo  dizziness,  headache,  nor  any  pains,  except  some  in 
the  region  of  the  calves  when  they  are  compressed.  Extreme 
weakness  of  all  the  movements,  and  especially  of  those  of  the 
lower  extremities. 

Having  put  the  patient  in  a  condition  of  rest,  having  limited 
the  quantity  of  drink  to  what  was  absolutely  necessary,  and 
after  regulating  the  diet  (at  the  beginning  all  his  food  and 
drink  consisted  of  a  glass  of  tea  without  sugar  in  the  morning, 
a  half-glass  of  bouillon  and  a  small  cutlet  for  dinner,  and  six 
glasses  of  milk  durmg  the  whole  day ;  later  on,  with  the  im- 
provement of  the  patient,  the  diet  was  accordingly  changed), 
we  prescribed  eight  tablespoonfuls  of  strong  Crimea  wine  per 
day,  the  mixture  of  the  aether- valerianate  and  Hoffman's  drops 
aa  at  the  beginning  up  to  200  drops  per  da}',  digitalis  m  an 
infusion,  altogether  twenty-four  grains  during  the  fii\st  two  days, 
a  large  Spanish  fly  over  the  region  of  the  heart,  and  a  clyster  in 
case  of  necessity.  By  the  third  day  there  occurred  some  slight 
improvement :  the  pulse  was  98,  the  dyspnoea  somewhat  less 
severe  and  the  amount  of  urine  was  2500  c.c.  ;  but  on  the  next 
day  the  dyspnoea  became  again  aggravated,  and  the  urine  fell 
to  onl}'  1500  c.c.  As  the  clyster  evacuated  the  bowels  insuffi- 
ciently and  the  abdomen  was  very  much  distended,  we  gave 
him  calomel,  one  grain  every  hour :    after  the    fifth  dose  the 


—  452  — 

patient  had  abundant  loose  dark-green  evacuations,  the  respira- 
tion became  easier,  but  the  amount  of  urine  did  not  increase. 
We  then  resorted  again  to  the  infusion  of  digitalis,  twenty-four 
grains  during  two  days ;  the  stimulants,  namely  the  wine  and 
the  above-2iamed  drops,  were  given  to  the  patient  during  all  the 
time  that  he  remained  in  the  clinic,  —  later  on  in  smaller  doses 
in  accord  with  the  improvement  of  the  pulse:  only  during  the 
last  days  before  patient  left  the  clinic  did  we  leave  off  these 
drops. 

The  second  dose  of  digitalis  given  together  with  the  stimu- 
lants in  the  first  large  dose,  failed  to  markedly  improve  either 
the  pulse  or  the  respiration,  or  to  increase  the  amount  of  urine 
over  2000,  and  did  not  produce  any  marked  decrease  of  the 
signs  of  oedema.  Putting  then  aside  the  digitalis  and  continu- 
ing the  stimulants,  sodium  iodide  (~ij  to  3VJ)  was  ordered  in 
Ems  water  (in  view  of  the  continuing  dyspeptic  symptoms), 
a  tablespoonful  in  a  quarter  of  a  glass  of  the  water  (altogether 
between  one  and  one  and  a  half  glasses  of  Ems  per  day). 
March  15th,  twenty  grains  of  sodium  iodide ;  16th,  thirty 
grains;  17th  and  18th,  forty  grains  each:  the  urine  rose  to 
3000  c.  c.  in  quantity,  the  signs  of  oedema  began  to  diminish, 
the  pulse  became  less  frequent  (78-72),  breathing  grew  easier, 
sleep  better,  the  temperature  fell  to  the  normal.  From  March 
19th  to  2od  he  had  fifty  grains  of  sodium  iodide  per  day,  from 
the  23d  to  the  28th  sixty  grains ;  with  the  former  quantity  of 
drink  the  urine  amounted  to  -1000  c.c.  ;  the  cedema  passed 
away,  the  breathmg  became  free  (20-18),  the  sleep  quiet;  the 
li\'er  has  diminished  considerably  in  size  and  is  not  sensitive, 
the  pulse  became  regular  and  strong,  but  is  still  frequent  (96- 
100).  He  was  again  given  iufusion  of  digitalis  (twentj^-four 
grains  of  digitalis)  during  two  days,  but  without  any  appreciable 
result.     We  then  again  resorted  to  sodium  iodide. 

We  must  now  say  a  few  words  concerning  the  condition  of 
the  patient's  nervous  system.  Notwithstanding  the  consider- 
able decrease  in  the  extent  of  the  oedema  and  the  increase  of 
the  patient's  strength,  the  weakness  in  the  movements  of  the 
legs,  which  was  ascribed  to  general  debility  and  to  the  great 
weight  of  the  legs  on  account  of  the  (jedema,  remained  in  the 
former  condition  :  the  patient  was  unable  to  either  walk,  or 
to  even  stand  erect ;  we  could  not  bring  out  any  tendon 
reflexes  in  the  legs  (the  sensibility  was  preserved).  Massage 
failed  to  improve  the  condition  of  the  lower  extremities.  Such 
a  paretic  state  of  the   legs  and  a  considerable   weakening   of 


—  453  — 

the  memory,  in  the  presence  of  an  undoubted  syphilitic  infec- 
tion of  the  organism,  have  naturally  led  us  to  suspect  a  syphi- 
litic infection  also  of  the  nervous  system ;  we  therefore  continued 
the  specific  treatment  the  more  persistently,  constantly  increas- 
ing the  dosage  of  the  sodium  iodide,  from  <jO  grains  per  day  to 
90,  100  and  120.  By  April  19th  the  patient's  condition,  out- 
side of  that  of  the  legs,  was  entirely  satisfactory  :  the  appetite 
was  good,  the  digestion  regular,  the  amount  of  urine  was  always 
1800  c.  c.  in  twenty-four  hours,  the  dimensions  of  the  liver 
almost  normal  (the  signs  of  ascites,  as  mentioned  above,  dis- 
appeared even  before),  breathing  free,  no  palpitation,  the  pulse 
7S  to  80,  regular  and  strong,  the  dimensions  of  the  heart  de- 
creased (the  percussion  sounds  on  the  inferior  part  of  the  chest 
are  clear);  there  remained  the  weak -systolic  murmur  at  the 
sternum ;  the  sleep  is  good,  the  mental  state  hearty,  the  memory 
better,  nutrition  and  strength  are  normal ;  but  the  weakness  of  the 
lower  extremities  has  not  passed  away,  although  it  has  diminished 
somewhat.  April  1 9th.  he  was  given  eighty  grains  of  sodium 
iodide,  and  since  the  2()th.  sixty  grains  a  day  and  at  the  same 
time  inunctions  with  mercurial  ointment.  3j  per  day,  in  con- 
junction of  course  with  a  mouth  wash  of  a  potassium  chlorate 
solution.  With  the  aid  of  inunctions  the  condition  of  the 
lower  extremities  began  to  improve  rapidly.  May  the  first,  the 
patient  was  compelled  by  his  official  duties  to  leave  the  clinic ; 
by  this  time  he  was  able  to  walk  almost  as  well  as  any  healthy 
man,  and  the  tendon  reflexes  returned;  but  he  was  advised  to 
continue  the  specific  treatment  for  another  three  weeks  so  as 
to  obtain  a  lasting  benefit  from  this  treatment  which  he  bore  so 
well. 

In  this  case,  outside  of  syphilis  of  the  heart  and  of  the  nervous 
system,  there  was  probably  also  a  syphilitic  affection  of  the  liver. 
It  is  true,  that  enlargement  as  well  as  tenderness  of  this  last 
might  also  have  been  due  to  blood  stagnation,  in  the  presence 
of  a  general  disturbance  of  the  circulation,  and  also  to  alcohol- 
ism ;  but  the  considerable  ascites  indicates  not  only  a  condi- 
tion of  stagnation,  but  a  more  serious  affection  of  the  liver,  and 
that  this  last  was  of  syphilitic,  rather  than  of  an  alcoholic  nature, 
is  seen  from  the  rapid  improvement  in  the  condition  of  the  liver 
under  the  influence  of  the  iodide  treatment. 

As  far  as  the  diagnostication  of  the  cardiac  condition  in  the 
above-described  cases  is  concerned,  we  are  compelled  to  infer  in 
the  first  case,  if  not  a  pure,  then  a  preeminent  affection  of  the  car- 
diac muscle,  namely  syphilitic  myocarditis ;  in  the  second,  third. 


—  454  — 

fourth,  a  preeminent  syphilitic  affection  of  the  cardiac  nerves ; 
and  in  the  last  as  well  as  in  those  of  which  it  serves  as  a  type, 
namely,  in  the  majority  of  the  cases  of  "cardiac  syphilis,  as  ob- 
served by  me,  a  simultaneous  syphilitic  affection  of  both  the 
muscle  and  the  nerves  of  this  organ.  I  did  not  come  across  a 
case  of  cardiac  syphilis,  which  would  present  evident  objective 
symptoms  of  an  affection  of  the  valves  and  of  the  cardiac  orifices 
and  in  which,  with  the  improvement  of  the  heart  activity  and 
circulation,  these  symptoms  would  disappear. 

To  judge  from  the  foregoing,  the  chief  basis  for  the  diagnosis 
of  cardiac  syphilis,  as  well  as  of  syphilis  of  the  other  internal 
viscera,  is  found  in  the  anamnestic  data  and  in  the  simultaneous- 
ly occurring  symptoms  of  syphilis  in  other  parts  of  the  organ- 
ism. As  regards  the  anamnesis,  we  are  far  from  relying  upon 
what  the  patient  asserts  or  denies  concerning  syphilitic  infec- 
tion. Both  the  assertion  and  the  denial  are  to  be  considered 
critically  ;  while  denying,  the  patient  may  hide  the  truth  pur- 
posely, or  he  may  do  so  bona  fide,  without  any  suspicion  on  his 
part  of  ever  having  been  infected  by  syphilis  :  on  the  other  hand 
the  patient  may  mistake  a  syphilitic  infection,  although  this  hap- 
pens but  seldom.  To  verify  these  assertions  and  to  obtain  reli- 
able data  for  the  diagnosis  we  must  resort  to  a  thorough  inves- 
tigation of  the  past  history,  of  the  phenomena  which  the  patient 
considered  as  syphilitic,  of  whether  there  was  any  falling  out  of 
hair  of  the  head,  and  especially  of  the  eyelashes  and  beard,  of 
characteristic  eruptions,  nocturnal  pains,  etc.,  and  also  as  to 
whether  the  patient  subjected  himself  to  iodide  and  mercury 
treatment  and  as  to  the  influence  of  such  treatment  on  his  con- 
dition. As  indications  for  the  diagnosis  may  also  serve  the 
absence  of  other  causes  of  the  cardiac  affection  (as  in  our  first 
case),  and  the  slight  effectiveness  of  non-specific  treatment. 

The  specific  treatment  instituted  for  the  sake  of  verifying 
the  diagnosis  of  cardiac  syphilis,  is  the  same  as  applied  in  other 
cases  of  late  syphilitic  affections ;  if  the  patient  has  formerly 
subjected  himself  to  a  sufficient  mercurial  treatment,  then  the 
iodide  preparations  usually  exert  a  favorable  effect,  and  the  iodide 
treatment  alone  may  be  sufficient  to  improve  the  patient's 
condition  ;  otherwise,  it  becomes  necessary  to  resort  to  mercury, 
alone  or  in  combination  with  the  iodide  preparations,  which 
last  are  in  such  cases  administered  in  smaller  doses  than  when 
the  iodides  alone  are  used.  As  what  concerns  the  non-specific 
treatment  of  the  cardiac  therapy  in  general,  I  intend  to  return 
to  it  at  some  other  time.     However  the  last  full}^  described  case 


—  455  — 

of  cardiac  syphilis  gives  a  sutiiciently  clear  idea  as  to  wliat  rem- 
edies of  general  cardiac  therapy  are  to  be  employed  in  syphi- 
litic affection  of  the  heart.  The  same  case  makes  it  clear,  that 
if  the  indications  of  the  presence  of  syphilis  be  sufficient,  then 
there  is  no  need  to  hesitate  with  the  ordering  of  a  specific 
treatment. 

I  will  take  the  opportunity  to  touch  now  on  two  remedial 
agencies  in  the  domain  of  cardiac  therapy,  the  so-called 
milk  treatment  of  diseases  of  the  heart,  and  the  application  of 
Spanish  flies  to  the  region  of  the  heart. 

As  far  as  the  first  is  concerned,  its  name  contains  an  inaccu- 
racy which  may  be  the  cause  of  mistaken  application  of  the 
milk  treatment  for  such  cases  of  cardiac  disease,  in  which  it  is 
both  unnecessary  and  unsuitable.  The  milk  treatment  exerts 
its  effect  not  on  the  diseases  of  the  heart  (except  in  one  case, 
of  which  presently),  but  on  their  complications,  such  as  ascites, 
abdominal  disorders  (dyspepsia,  constipation,  enlarged  abdomen 
due  to  gastro-intestinal  meteorism.  and  abdominal  obesity)  and, 
less  frequently,  general  obesity.  It  is  true  that  in  cases  of  as- 
cites caused  by  cardiac  disease,  milk  serves  as  the  best  diuretic, 
when  it  becomes  necessary  to  act  tlxrough  the  kidneys  (and 
when  we  desire  to  act  through  the  heart,  we  resort  to  digitalis 
and  to  similar  drugs)  ;  it  is  also  true  that  the  complications  of 
cardiac  diseases  in  the  form  of  abdominal  disturbances  are  verj- 
frequent  and  serve  as  the  chief  cause  for  the  presence  of  obsti- 
nate dyspnoea,  cardiac  asthma,  angina  pectoris,  and  the  circula- 
tory disturbances,  and  that  the  removal  of  these  complications 
by  the  aid  of  a  strict  milk  treatment  (at  the  beginning  milk 
only,  and  later  on  milk  with  meat,  fish,  and  eggs,  but  no  carbo- 
hydrates) is  attended  with  splendid  results  ;  however,  the  milk 
treatment  acts  solely  on  the  above-nahied  complications,  and 
not  on  the  heart  itself,  and  to  prescribe  this  treatment  for  cases 
of  cardiac  diseases  unattended  with  such  complications  —  which 
is  often  done,  thanks  to  the  erroneous  idea  conveyed  by  the 
name  ("  of  the  diseases  of  the  heart "'  )  —  is  a  procedure  devoid  of 
any  purpose  and  tending  to  weaken  the  patient.  There  is  only 
one  case  m  Avhich  the  milk  treatment  may  exert  a  direct  action 
on  the  heart,  namely  in  the  condition  of  fatty  heart  resulting 
from  general  obesity :  it  is  admissible  to  assume  that  with  the 
general  emaciation  which  usually  follows  the  milk  treatment, 
there  also  occurs  a  diminution  in  the  fat  of  the  heart.  If  the 
syphilitic  affection  of  the  heart  becomes  complicated  by  ascites, 
abdominal   disturbances   and  obesity,   then   in  prescribing  the 


—  456  — 

treatment  we  should  take  into  account  such  a  condition  of 
affairs,  and  so  we  did  in  the  last  of  the  described  cases  of  car- 
diac syphilis. 

I  will  now  take  up  the  use  of  Spanish  flies.  Some  seven 
years  ago  (February,  1882)  I  called  the  attention  in  a  commu- 
nication before  the  Physio-Medical  Society  to  the  value  of 
Spanish  flies  in  peripheral  neurites.  Since  that  time  I  had  fre- 
quent occasions  to  observe  a  considerable  and  lasting  improve- 
ment from  the  application  of  flies  to  the  region  of  the  heart, 
to  either  the  right  or  the  left  side  of  it,  as  well  as  above  or 
below  the  left  nipple  (in  women,  to  the  left  mammary  gland) 
in  angina  pectoris,  usually  in  cases  of  such  a  nature  :  in  patients 
no  longer  young,  mostly  gouty,  sometimes  with  symptoms  of 
chronic  arteritis.  The  attacks  of  angina  pectoris  were  usually 
caused  by  colds,  appearing  when  the  chest  was  subjected  to  a 
cold  blast,  or  after  the  inhalation  of  cold  air. 

The  examination  of  the  chest  in  the  region  of  the  heart  in 
such  cases  usually  elicits,  skin  hyperaesthesia  being  absent, 
pain  on  pressing  the  ribs  (periostites  of  the  ribs)  and  the  inter- 
costal spaces  (intercostal  neurites).  Quite  frequently  the  other 
parts  of  the  chest,  especially  its  left  side,  present  the  same 
phenomena ;  but  the  pain  is  usually  most  marked  on  pressing 
those  intercostal  spaces  which  correspond  to  the  locality  of  the 
heart,  which  circumstance  leads  us  to  assume  the  existence  also 
of  a  neuritis  of  the  cardiac  plexus  in  such  cases.  The  attacks 
themselves  of  angina  pectoris  are  quite  characteristic,  the  pain 
being  transmitted  to  the  left  arm  down  to  the  very  fingers. 
Outside  of  Spanish  flies  and  other  necessary  treatment,  I  usually 
advise  such  patients  to  wear  a  woolen  or  silk  chest  protector  so 
as  to  avoid  any  possibility  of  catching  cold.  But  in  cases  of 
attacks  of  angina  pectoris  in  syphilitic  cardiac  affection,  the  ap- 
plication of  Spanish  flies  to  the  affected  spot  produces  but  an 
insignificant  and  rapidly  passing  relief,  and  should  not  there- 
fore be  recommended. 

The  observations  brought  forth  in  this  communication  give 
one  an  idea  of  the  clinical  picture  of  cardiac  syphilis,  and 
stand  witness  to  the  fact  that  this  last  may  yet  be  recognized 
early  enough  to  be  treated  successfully  and  lastingly  to  no 
lesser  degree  than  is  the  case  with  syphilis  of  other  internal 
organs. 


—  457 


Additional  Notes. 


First.  As  is  well  known,  the  iodides  are  recommended  and 
used  also  in  simple,  non-syphilitic  sclerosis  and  atheromatosis 
of  the  arteries  and  the  myocarditis  following  thereon.  I  have 
seen  a  great  many  patients  suffering  with  the  above-named 
diseases,  who  had  been  taking  for  a  long  time  the  iodides  of 
potassium  and  sodium ;  but  never,  not  in  one  single  instance, 
even  when  large  doses,  as  thirty  to  forty  grains  per  day,  of  these 
remedies  were  used,  have  I  observed  such  a  positive,  incontro- 
vertible success,  as  I  saw  in  the  treatment  by  the  iodides  and 
by  mercury  of  the  same  affections  when  of  syphilitic  origin.  I 
do  not  consider  it  improbable,  that  in  the  cases  in  which  cer- 
tain observers  noted  such  a  success,  syphilis  was  an  element  in 
the  development  of  these  affections. 

Second.  During  the  year  I  had  occasion  to  observe  a  few 
more  cases  of  cardiac  syphilis ;  but  as  they  present  nothing 
different  from  the  above  conclusions,  I  do  not  consider  them 
here.  I  think  however,  that  the  following  case  of  aneurism 
of  the  aorta  (and  probably  of  the  innominate  artery)  as  resulting 
from  syphilitic  aortitis,  is  of  sufficient  interest  to  be  brought 
forward. 

February  6,  1890,  a  patient,  thirty-seven  years  old,  entered 
our  clinic,  complaining  of  pains  in  the  right  half  of  the  head 
and  in  the  right  shoulder,  and  also  of  palpitation  and  dyspnoea. 

He  lives  in  a  good  locality  and  in  a  fairly  good  house.  He 
does  not  bathe  in  the  river;  takes  a  hot  bath  weekly  and 
perspires  freely.  Does  not  smoke,  drinks  always  brandy  and 
sometimes  to  excess,  also  a  great  deal  of  hot  and  strong  tea ; 
has  good  board.  Patient  has  a  great  many  occupations  of  a 
troublesome  nature ;  has  to  talk  loudly,  to  travel  in  jolting 
carriages  and  sleighs  over  poor  roads,  and  conducts  a  considera- 
ble correspondence.  He  was  infected  with  syphilis,  later  got 
married;  out  of  six  children  three  were  still-born,  the  fourth 
died  in  early  infancy,  the  fifth  is  sickly,  the  sixth  is  as  yet 
well. 

Anamnesis.  —  When  twenty-four  years  old,  patient  was  in- 
fected with  syphilis,  was  treated  for  two  months  by  mercury, 
and  to  some  extent  by  the  iodides,  and  since  then,  considering 
himself  recovered,  he  resorted  to  no  antisyphilitic  treatment. 
During  the  last  four  years  patient  had  at  times  pains  in  the 
legs  day,  and  night ;  while  one  year  ago  there  appeared  pains 
in  the  right  half  of  the  head  and  in  the  right  shoulder,  which 


—  458  — 

gradually  increased.  Lately  these  pains  have  prevented  good 
sleep  and  patient  grew  emaciated.  Five  months  ago  there 
appeared  palpitation  of  the  heart  and  a  swelling  on  the  lower 
portion  of  the  right  side  of  the  neck,  which  kept  continually 
increasing  in  size,  so  that  lately,  on  account  of  the  swelling,  he 
has  been  unable  to  button  his  shirt-collar. 

Status  Feb.  6,  1890.  —  Patient  is  of  strong  constitution  and 
good  nutrition.  The  appetite  is  fair,  digestion  regular,  the 
liver,  spleen,  kidneys,  and  the  urinary  bladder  are  in  a  normal 
condition.  There  is  palpitation  of  the  heart,  some  dyspnoea,  and 
a  slight  dry  cough.  Objective  examination  of  the  chest  shows 
nothing  abnormal  in  the  respiratory  passages,  while  the  organs 
of  circulation  present  the  following  :  a  strong,  visible  impulse 
of  the  cardiac  apex  two  fingers'  width  outside  the  left  mammil- 
larj^  line,  between  the  sixth  and  seventh  ribs  ;  a  pulsating 
tumor  in  the  region  of  the  right  sterno-clavicular  articulation ; 
on  percussion  a  dull  sound  over  the  tumor  and  over  the  upper 
third  of  the  sternum  ;  percussion  over  the  other  two-thirds  of 
the  same  elicits  normal  clearness  ;  on  auscultation,  a  systolic 
murmur  along  the  whole  line  from  the  apex  of  the  heart  up  to 
the  above-mentioned  tumor,  especially  so  over  the  sternum 
and  to  its  right;  there  is  also  heard  over  the  sternum  a 
slight  diastolic  murmur  pointing  to  an  affection  also  of  the 
aortic  valves,  namely,  insufficiency  ;  over  the  carotid  arteries 
a  systolic  murmur,  but  no  heart  tone  is  heard.  The  pulse  is 
between  80  and  90,  of  regular  rhythm,  somewhat  weak,  weaker 
on  the  left  than  on  the  right  hand.  No  fever.  The  above- 
described  pains  on  the  right  side  of  the  head  and  right  shoulder 
prevent  sleeping ;  he  is  unable  to  rest  on  the  right  side ;  the 
right  arm  is  so  weak  that  patient  is  unable  to  write.  These 
pains  and  weakness  depend  evidently  on  pressure  of  the  tumor 
on  the  right  brachial  plexus. 

Outside  of  regulating  the  regimen  and  diet,  he  was  given  the 
following :  some  wine,  tra.  valer.  aether,  andliqu.  anodyn.  Hoffm. 
aa,  when  the  pulse  is  weak,  and  constantly  increasing  doses  of 
sodium  iodide,  beginning  with  ten  grains  a  day  up  to  eighty  (dur- 
ing the  last  week  before  he  left  the  clinic).  As  we  intended  to 
administer  large  doses  of  sodium  iodide,  and  as  this  iodide,  just 
as  that  of  potassium,  is  better  borne  by  the  stomach  and  intes- 
tines in  alkaline  solutions,  we  gave  it  to  him  dissolved  in  Vichy ; 
-'but  as  this  caused  some  looseness  of  the  bowels,  we  replaced  after 
two  days  the  Vichy  by  Ems  water,  and  with  this  the  iodide  was 
very  well  borne.  Both  the  Vichy  (Celestins)  and  the  Ems  (Kessel- 


—  459  — 

brunnen)  were  used  as  natural  waters,  at  the  temperature  of 
warm  milk,  to  the  quantity  of  half  a  glassful  during  the  day. 
Simultaneously  with  the  administration  of  the  sodium  iodide 
there  were  made  twelve  mercurial  inunctions,  at  first  in  one- 
half  drachm  doses,  and  later  in  drachm  doses.  In  the  intervals 
between  the  inunctions  the  patient  was  sponged  with  a  mixture 
of  water  and  brandy  at  the  temperature  of  warm  milk  and 
somewhat  cooler,  which  diminished  the  sweating  and  strength- 
ened him. 

March  12,  1890,  patient  left  the  clinic  in  the  following 
condition :  all  the  pains  disappeared,  he  can  lie  on  the  right 
side  ;  the  sleep  is  good ;  the  right  arm  is  completely  serviceable, 
patient  can  write  freely ;  the  tumor  in  the  region  of  the  right 
sterno-clavicular  articulation  has  diminished  so  much  that  he 
can  freely  button  his  shirt ;  the  pulsation  of  the  swelling  is  so 
insignificant  that  it  can  be  detected  only  by  touch,  but  not  by 
the  eye,  as  was  the  case  formerly;  the  pulse  of  the  right  arm 
has  become  fuller ;  the  symptoms  obtained  by  percussion  and 
auscultation  have  not  changed ;  the  palpitation  does  not  trouble 
the  patient  any  more,  and  he  declares  that  in  a  general  way  he 
feels  well  and  cannot  complain  of  anything. 

The  patient  was  advised,  outside  of  preserving  a  regular 
mode  of  living  and  caution  required  by  the  condition  of  his 
chest,  to  continue  the  sodium  iodide  for  a  few  more  days  (up  to 
six  weeks),  and  to  repeat  the  treatment  in  summer.  Up  to 
recently  (November,  1890),  as  we  have  heard,  the  condition  of 
the  patient  continues  as  satisfactory  as  when  he  left  the  clinic. 

My  last  observations  (1891)  on  cardiac  syphilis,  in  the 
clinic  as  well  as  in  private  practice,  completely  substantiate  all 
the  above  assumptions. 


TREATMENT  OF  FEVER. 

(A  Therapeutic  Note.) 


Shall  we  treat  fever,  and  if  yes,  how  ? 

At  the  present  time  there  are  those  who  assert  that  the  fever 
accompanying  the  acute  infectious  diseases  must  not  be  treated, 
because  it  forms,  as  it  were,  a  protecting  agency  to  the  organism 
against  the  pathogenic  factor.  Without  denjdng  not  only  the 
possibility,  but  even  the  probability  of  such  a  process  of  self- 
protection,  we  nevertheless  are  unable  to  draw  conclusions  there- 
from to  the  effect  that  the  fever  must  be  left  untreated.  Is 
not,  for  instance,  the  cough  in  certain  cases  (as  in  bronchial 
catarrh  with  abundant  secretion,  in  oedema  of  the  lungs  and  so 
on)  a  self-protecting  agency  to  the  organism,  without  which 
the  patient  would  suffocate,  —  a  beneficial  symptom  which  in 
such  cases  must  not  be  weakened,  but  on  the  contrary  strength- 
ened, and  are  we  not  compelled  in  other  cases,  as  even  in  this 
same  bronchial  catarrh,  to  relieve  the  too  severe  cough,  if 
it  tends  to  impair  the  sleep,  and  to  act  injuriously  or  even 
dangerously  on  the  cerebral  circulation,  on  the  cardiac  activity, 
on  the  condition  of  the  abdominal  organs,  etc.  ?  The  same 
may  be  said  of  diarrhiDea,  and  of  other  symptoms  which  are  bene- 
ficial to  a  certain  degree,  and  become  injurious  as  soon  as  this 
degree  is  overstepped;  the  same  applies  to  fever  in  connection 
with  infectious  diseases,  and  consequently  the  physician  must 
consider  it  in  the  same  light  in  which  he  considers  the  other 
symptoms  of  a  similar  nature,  namel}^  not  to  treat  it,  if  he 
has  reason  enough  to  consider  its  presence  beneficial  and  as 
long  as  it  does  not  overstep  certain  bounds,  and  to  t  reat  it  in 
the  contrary  case. 

How  is  fever  to  be  treated?  In  cases  where  the  radical  treat- 
ment, not  only  of  the  febrile  symptoms,  but  of  the  disease  it- 
self (as,  for  instance,  in  malaria,  in  acute  articular  rheumatism) 
is  possible,  the  modus  operandi  for  the  physician  needs  no  explan- 
ation. 

In  the  acute  infectious  diseases  for  which  we  possess  no  rad- 
460 


—  461  — 

ical  treatment,  as,  for  instance,  in  typhus,  typhoid  and  recurrent 
fevers,  influenza,  croupous  pneumonia,  erj^sipelas,  etc.,  I  act  as 
follows :    If  the  fever  is  moderate,  and  if  by  analyzing  the  pa- 
tient's condition  I  am  unable  to  detect  any  undoubted  deleterious 
influence   on  the  patient  therefrom,  then  I  wait;   otherwise  I 
resort  to  treatment.     What  is  the  degree  of  temperature  that 
constitutes  a  moderate  fever  ?     We  must,  of  course,  first  of  all 
individualize  our  case :    aged  people  are  less  able  to  bear  a  tem- 
perature of   39°  R.  (102.2°  F.)  than  children  will  bear  one  of 
40°  R.  (104°  F.')  and  higher;    but  speaking  in  a  general  way, 
a    temperature   of  39°   R.   (102.2°  F.)  in  adult,  but  not  aged 
persons,  need  but  seldom  trouble  the  physician,  whereas   one 
of  40°  R.  (104°  F.')  and  above  excites  apprehensions.      The 
greatest  care  and  most  thorough  inquiry  about  the  condition  of 
the  patient  is  required  in  case  of  a  temperature  ranging  between 
39°i^.  (102.2°  F.)  and  40°  R.  (104°  F.~).  —  In  such  cases,  as, 
for  instance,  in  typhoid  fever,  if  there  be  present  no  other  trou- 
blesome symptoms,  I  do  not  treat  the  fever.     If  with  such  a 
temperature    there  be  also  present  some  dangerous   symptom, 
then,  before  taking  up  the  treatment  of  the  fever,  I  seek  for 
other  possible  causes  of  this  sjanptom  outside  of  the  high  tem- 
perature :  if  I   observe,  for  instance,   depression  of  the  cerebral 
activity,  and  simultaneously  with  this  symptoms  indicating  an 
influx  of  blood  to  the  brain  (as  a  flushed  face),  as  frequently 
occurs  in  typhoid  fever  (and  often  passes  away  with  a  sponta- 
neous nose-bleed),  then  I  order  not  antipyretics,  but  two  leeches 
to  the  nasal  septum,  and  an  ice-bag  on  the  head,  which  is  often 
sufficient  to  bring  relief;  if  I  note  mental  depression  with  a 
pale  face,  then  I  wash  the  head  in  cold  water,  administer  musk, 
and  sometimes  —  usually  during  the  further  course  of  the  disease, 
when    there    appears   a    threatening  oedema  of  the  brain,  —  I 
apply  a  Spanish  fly  to  the  nape  of  the  neck;  for  a  weak  pulse, 
especially  m  persons  habituated   to  the  use  of  alcoholic  drinks, 
I  give  wine,  cognac  and  stimulants ;  in  other  cases,  to  remove 
the  troublesome  symptoms,  we  are  compelled  to  administer  lax- 
atives (in  cases  of  constipation  and  intestinal  meteorism),  and 
so  on.    But  if,  after  analyzing  the  patient's  condition,  I  find  no 
reason  to  expect  any  benefit  from  the  use  of  the  above-enumer- 
ated and  similar  means,  or,  on  applying  the  same,  I  do  not  ob- 
tain any  sufficient  relief  and  am  compelled  to  refer  the  dangerous 
symptoms  to  the  rise   in  temperature,  then  I  resort  to  antipy- 
retic  treatment  —  calomel,  cool  bathing,  antifebrine    (less   fre- 
quently antipyrine),  phenacetine,  sodium  salycilate,  and  quinine. 


—  462  — 

The  indications  for  the  use  of  calomel  in  certain  febrile  af- 
fections, as  typhoid  fever,  croupous  pneumonia,  erysipelas,  and 
acute  nephritis  have  been  spoken  of  before  (vide  p.  427). 

Cool  baths  —  temperature  24:°  to  22°  H.,  lowering  it  while 
the  bath  is  being  given  to  20°-18°.  The  duration  of  the  bath 
must  be  determined  by  the  peculiarities  of  the  given  case  ;  the 
first  bath  is  to  be  taken  in  the  presence  of  a  physician,  the  fol- 
lowing ones  under  the  supervision  of  a  skilled  assistant.  The 
patient  is  lowered  into  the  bath  and  raised  therefrom  on  a  sheet. 
The  chief  contraindications  for  this  procedure  are:  diarrhoea, 
intestinal  hsemorrhages,  poor  cardiac  activity,  embarrassed  res- 
piration, as  from  a  severe  bronchitis  with  hypostasis  or  from  a 
superadded  pneumonia,  and  great  excitement  of  the  nervous 
system.  The  chief  indication  for  its  use,  besides  the  lowering 
of  the  temperature,  is  a  depressed  state  of  the  nervous  system. 
Cool  spongings  of  the  whole  body  with  vinegar  and  water  are 
necessary  for  cleanliness'  sake,  and  are  usually  pleasant  to  the 
patient,  for  they  cause  a  slightly  stimulating  effect  on  the  ner- 
vous system,  but  their  influence  on  lowering  the  temperature  is 
certainly  very  insignificant. 

Let  me  add  that  at  times,  most  frequently  in  typhoid  fever, 
we  must  resort  to  another  hydro  therapeutic  measure,  namely,  in 
the  following  cases,  usually  during  the  further  course  of  the 
typhoid,  when  the  patient  has  become  considerably  exhausted: 
burning  heat  in  the  trunk,  cold  extremities,  a  very  weak  pulse, 
great  mental  excitement,  as  evidenced  by  insomnia  and  constant 
delirium.  In  such  cases  I  adramister  bromides  and  place  the 
body,  as  it  were,  in  a  warm  compress :  several  flannel  comfort- 
ers are  spread  over  the  bed,  on  top  of  which  is  put  a  sheet 
soaked  in  water  cooler  than  lukewarm ;  the  patient,  completely 
naked,  is  placed  on  the  sheet,  which  is  wrapped  around  him,  and 
over  this  the  comforters.  Such  treatment  is  in  the  majority  of 
cases  successful :  the  patient  is  quieted  down,  the  delirium 
ceases  and  he  falls  asleep,  the  burning  heat  m  the  back  and  the 
cold  in  the  extremities  pass  away,  and  the  pulse  improves. 

Antipyrine,  antifebrine  and  phenacetine  I  use  ordinarily  in 
the  following  manner :  I  give  a  five-grain  dose  (less  frequently 
three  grains):  in  the  majority  of  cases  I  obtain  a  lowering  of 
the  temperature  down  to  39°  E.  and  lower,  and  as  long  as  this 
lasts  I  do  not  administer  any  more.  As  soon  as  the  tempera- 
ture has  risen  again  to  over  39°,  I  repeat  the  same  dose,  and  so 
on ;  consequently  I  do  not  in  the  least  attempt  to  bring  the 
temperature  down  to  its  normal  condition,  but  am  content  to 


—  463  — 

lower  it  sufficiently  to  exclude  any  possible  danger  (the  same  is 
to  be  said  of  the  use  of  cool  baths).* 

I  use  most  frequently  phenacetine  or  antifebrine,  and  if  they 
lose  their  effect  or  the  patient  becomes  habituated  to  them,  then 
I  resort  to  antipyrine  or  sodium  salycilate  (in  ten-gram  doses). 

Outside  of  malaria,  I  give  quinine  in  those  cases  m  which  the 
febrile  condition  is  of  a  strongly  exhausting  or  directly  inter- 
mittent nature  (in  the  febrile  condition  of  the  continual  fever, 
quinine  acts  only  when  given  in  very  large  doses,  which  are 
borne  rather  difficultly,  and  even  then  it  acts  slightly  and  for  a 
short  time),  most  frequently  in  febrile  catarrhs  of  the  respira- 
tory passages,  in  prolonged  pneumonia,  in  influenza  and  ty- 
phoid fever,  if  the  condition  of  the  intestines  permits  it,  when 
from  being  constant  the  fever  becomes  a  severely  exhausting  or 
an  intermittent  one  ;  for  constant  fever  I  give  antifebrine,  phena- 
cetme  and  antipyrine.  I  administer  it  usually  during  the  period 
of  exhaustion  or  during  the  intermittence,  and  therefore  in  the 
majority  of  cases  in  the  morning,  not  on  an  empty  stomach,  but 
after  the  tea  or  coffee,  and  not  in  the  evening,  as  is  usually 
recommended.  When  given  during  the  above-mentioned  periods 
the  quinine  acts  better,  probably  because  it  is  more  readily  ab- 
sorbed. I  do  not  increase  the  dose  of  quinine  until  the  appear- 
ance of  cinchonism,  as  we  do  in  malaria,  but  I  give  usually  five- 
grain  doses  once  or  twice,  rarely  three  times  a  day. 

For  pulmonary  tuberculosis  the  chief  antipyretic  and,  general- 
ly speaking,  the  chief  remedial  agent  is  certainly  creosote,  guai- 
acol,  or  guaiacol  carbonate;  but  before  we  are  able  to  obtain  a 
good  effect  from  them,  we  are  at  times  compelled  to  give  qui- 
nine m  the  exhausting  and  intermittent  fever,  and  for  the  con- 
stant fever,  antifebrine,  antipyrine  or  phenacetine,  while  sodium 
salicylate  is  but  little  effective  in  small  doses,  and  is  liable  to  im- 

*  The  lowering-  of  the  temperature  down  to  its  normal  condition  dur- 
ing the  whole  course  of  typhoid  fever  by  the  aid  of  cold  baths  and  the 
above-named  antipyretics  was  attempted,  but  did  not  become  a  generally 
adopted  practical  procedure,  and  is  recommended  but  by  very  few,  be- 
cause, first,  it  does  not  benefit  the  patient,  as  the  duration  of  the  disease 
is  not  shortened;  and  secondly,  it  may  become  injurious,  for  continuous 
cold  baths,  by  determining  an  increased  production  of  heat,  increase  the 
exhaustion  of  the  organism;  while  the  use  of  the  above-named  antipy- 
retics, which,  to  keep  the  temperature  constantly  down  to  its  normal  con- 
dition, must  be  given  in  large  doses,  may  tend  to  affect  the  heart  injuri- 
ously or  even  to  a  dangerous  extent:  not  to  speak  of  the  possible  harm 
from  the  cessation  of  the  fever,  which  may  act  as  a  self-protecting  agency 
to  the  organism.  Thus  some  observers  assert  that  in  cases  of  typhoid  fe- 
ver, which  were  j)ersistently  treated  by  the  application  of  cold  water,  re- 
currences were  more  frequent. 


—  464  — 

pair  digestion  in  large  ones,  and  I  therefore  prefer  the  above  an- 
.  tipyretics. 

In  septicaemia  and  pyaemia,  not  having  any  better  agents,  I 
give  creosote,  or  guaiacol  and  guaiacol-carbonate,  as,  for  in- 
stance, in  the  treatment  of  empyema  (outside  of  operative 
interference). 


INDEX. 


Aache^',  a  German  wateriug-place    . 
Abas-Touman,  a  Caucasian  watering-place 
Abdomen,  inquiry  about,  in  examining  a  patient 

"  method  of  palpating 

Acid,  boric,  in  choleraic  diarrhoea 

"      carbolic,  in  chronic  articular  affections     . 
'•      carbonic,  action  of,  in  the  stomach 
'•  "  external  effect  of  .         .         , 

"      hydrochloric,  employment  of,  in  diseases  of  the  stomach 
"  •'  "pseudo"   preventive  of  cholera 

"  "  secretion  of,  in  clironic  gastric  catarrh 

"  ■'  "  in  gastric  ulcer 

Acids,  organic,  effects  of,  in  hydrotherapy 
Accumulations  in  tbe  peritoneal  cavity,  treatment 
Agencies,  curative,  in  mineral  waters 
Air,  compressed,  in  pleurisy  .... 

Air-baths  in  parenchymatous  nephritis 

"  effects  of,  vide  Climatotherapy. 

Albuminates,  peptonized,  in  gastric  diseases     . 
Albuminuria  in  the  chronic  nephrites 
Alcohol  a  predisposing  factor  in  h8emorrhoid.'=  . 
"        in  the  algid  stage  of  cholera 
"         in  debility         ...... 

"         in  the  treatment  of  clioleraic  diarrhoea 
Alcoholic  drinks,  results  of  abrupt  abstinence  from 
Algeria  as  a  health  resort     . 
Algid  stage  of  cholera,  causation  of 
"  '■  "  treatment  of 

Aloe  as  a  laxative 
AnsBmia,  mineral  waters  in  . 
Anamnesis      .... 

"  definition  of 

health  of  parents  and  relatives 
"  as  regards  syphilitic  infection 

Andes,  the,  treatment  of  tuberculosis  in 
Aneurism  of  the  aorta,  case  of     . 
Angina  pectoris,  Spanish  flies  in 

"  •'  with  cardiac  syphilis 


PAGE 

341 

340 

13 

46 

379 

222 

f)0 

338 

.h 

83,  84 

371, 

372 
59 
125 
339 
199 
90 
272 

240.  24.5 

246 

85 

242, 

243 

398 

383 

4:5 

381 

203 

303 

365, 

366 

382. 

383 

1.52, 

1.53 

116 

8 

17 

17 

454 

304 

457 

456 

448 

449 

4th 


466 


Angioneurotic  nature  of  htemorrhoids 
Antifebrine  in  hectic  fever  . 
•'  in  pneumonia     . 

"  in  reaction  period  of  cholera 

.    "  in  treatment  of  fever 

Antipyrine  in  acute  articular  rheumatism 
"  in  hectic  fever    . 

"  in  pleurisy 

"  in  treatment  of  fever 

Anus,  bloodletting  from  circumference  of,  reasons  for 

"       inquiry  about,  in  examination  of  patient 
Aorta,  abdominal,  sensitiveness  of.  on  palpating  the  abdomen 
"        aneurism  of,  case  of  ..... 

Apoplexy,  venesection  in 

Arsenic  in  chlorosis       ....... 

"         ''         "  contraindications  to  use  of 

"         "  neurasthenia       ...... 

Arthritis  urica,  vide  Gout. 

Articular  affections,  chronic,  local  treatment  of 

Atelectasis,  pulmonary,  rales  in  . 

Atrophic  gastric  catarrh  (with  cancer  of  the  duodenum), 

Autopsies,  importance  of      . 


Bacterium  of  cholera 

Balneotherapeutic  treatment  applied  at  home  . 

"  "  course  of       .         .         . 

Balneotherapy,  elements  of  ..... 

"  lack  of  clinical  knowledge  about 

"  many-sidedness  of  the  subject  of 

"  in  chlorosis  ..... 

"  in  chronic  myosites,  neutrites,  etc.  . 

"  in  diseases  of  the  heart 

"  "  "        hfematopoiesis 

"  "  "        nutrition 

"  "  "        respiratory  organs 

skin        .    '     . 
"  in  febrile  conditions  .... 

"  in  metallic  poisoning 

"  in  scrofula  ...... 

"  in  syphilis 

{Vide  also  Hydrotherapy,  Mineral  waters,  Watering 
Baltic  Sea,  a  trip  to,  in  neurasthenia  .... 
Bathing,  river,  in  neurasthenia  .         .         . 

"         sea,  diseases  in  which  it  is  indicated  . 
"  "     effect  of  mechanical  influences  in 

"  "     effective  agencies  in       ...         . 

Baths,  action  of,  on  the  central  nervous  system 
"  "  "        temperature  of  the  body 


PAGE 

397 
292,  320 
320,  321 
383 
462 
212 
292 
268 
462 
398,  399 
12 
48 
457 
391,  392 
255,  256 
261,  262 
147 

223 

328 

156 

27 

361 
350 
350 
332 
44 
333 
257 
354 
353 
354 
353 
353 
354 
354 
354 
354 
354 


places,  etc.) 


101 
102 

346,  347 
339 
346 
335 

335,  336 


467 


Baths,  cool,  in  the  treatment  of  fever 

"        determination  of  necessary  temperature  of 
"        effects  of  cold  and  warm  .... 
"        cold  and  hot,  influence  of,  on  circulation,  etc 
"  "     uselessness  of,  in  pneumonia  . 

"        hot,  in  the  treatment  of  choleraic  diarrhoea 
"  "     air        .... 

"        fir-tree         .... 
"        Russian       .... 
"        warm,  drawbacks  in  use  of 
"  "        in  biliary  calculi    . 

"  "        for  promoting  sleep 

"  "        for  pains 

Bestujeff  s  tincture 
Biarritz,  a  trip  to,  in  neurasthenia 
Binz  on  calomel     .... 
Biliary  calculi,  vide  Calculi. 
Bilirubin,  formation  of  (foot-note) 
Bismuth  in  choleraic  diarrhoea    . 

"         in  ulcer  of  the  stomach  (foot-note) 
"         phenolate,  vide  Tribromphenolbismuth. 
Bitters,  use  of,  in  chronic  catarrh  of  the  stomach 
Black  Sea,  a  trip  to,  in  neurasthenia  . 
Bladder,  urinary,  inquiry  about,  in  examination  of  patient 
Blisters,  use  of,  in  pleurisy  . 

"  "        in  pericarditis     . 

Blood,  quantity  of,  extracted  in  derivative  bloodletting 
Bloodletting,  former  practice  of  . 
"  Moscow  practice  of 

"  recent  history  of     . 

"  views  of  different  authorities  on 

"  depletive  {vide  also  Venesection) 

"  derivative        .... 

"  "  case  where  employed 


PAGE 

462 
45 

334,  335 

33(5,  337 
320 
381 
347 
347 

349,  350 
52 
177 
51,  52 
228 
247 
101 

407,  409 

253 

379,  380 

131 


78 

101 

12 

269 

390 

392 

387,  389,  390 

390 

387,  388 

388 

391 

396 

399,  400 


"  indications  for: 

"  "  in  region  of  abdomen 

"  "  "  chest 

"  "  head 

"  "  "  spine 

"  methods  of  use:  care  in  performing 
"  "  number  of  leeches 

"  "  position  of  patient 

"  "  time  of  day 

"  "  where  applied . 

"  reasons  for  its  employment 

''  repetition  of  .... 

"  to  the  nasal  septum     . 
local,  employment  of     . 


in  large  hsemorrhoidal  nodes,  404 

404 
403 

401,  402 

402,  403 
404,  405 

405 
405 
405 
405 
:398,  399 
406 
402 
393 


—  468  — 

Bloodletting,  local,  with  depletion  in  view 

Botkin  on  clilorosis 

Brain,  diseases  of,  balneotherapy  in   . 

Breathing,  rough,  as  a  symptom 

Brehmer's  experiments  with  climatotherapy 

"  theories  on  the  influence  of  mountainous  localities 

Bright' s  disease,  vide  Nephritis. 
Bromide  of  sodium  in  reaction  stage  of  cholera 
Bromides  in  neurasthenia    .         .         .         .         . 
Bronchopneumonia,  chronic  tuberculous  . 
Broussai's  influence  on  the  practice  of  bloodletting 
Brown-Sequard's  theories  on  glandular  secretion 


plexus 


Caffeine  as  a  diuretic 

"  natrobenzoicum  in  the  algid  stage  of  cholera 

Cairo  as  a  health  resort 
Calculi,  biliary,  Ems  water  in 
"         formation  of 

"  ■'        peculiar  symptom  of 

•'  "         relation  to  neuralgia  of  the  hepatic 

"•         diagnosis  of         ...         . 
"         treatment  of,  when  discontinued 

"  "        and  cholangitis  catarrhalis 

Calomel,  action  of,  physiological 

"  as  a  diuretic 

"■  "    laxative  ...... 

'''         compared  with  castor  oil 

"  Xothuagel  (and  Rossbach)  on  the  use  of,  in  Ger 

"■  in  biliary  calculi    ..... 

"  in  catarrhal  jaundice    .         .         . 

"■  in  acute  nephritis 

"  in  cirrhosis  of  the  liver 

"  in  cholera       ...... 

"  in  pleurisy      ...... 

■'  in  pneumonia  ..... 

in  facial  erysipelas         .... 

"  in  typhoid  fever     ..... 

■'  use  of,  in  Germany,  France  and  England 

"  mode  of  employing        .... 

"  indication  for  use  of      . 

"  contraindication  to  use  of     . 

Camphor  in  the  algid  stage  of  cholera 
Cannes,  a  French  health  resort    .         .         . 
Cancer,  gastric,  differential  diagnosis  of     . 

"         duodenal  (4th  case)  .... 

"         of  pancreas  (5th  case)       .... 
Cantani's  description  of  an  oxaluric  patient 
"  treatment  of  choleraic  diarrhoja 


.317 


many 


191 


320, 


PAGE 

396 

251 
.351,  352 

327 
304,  305 

305 

383 
148 

277,  282 
387 
252 


246 
383 
303 
79,  166,  430 
169,  170,  176 

170,  171 
171,173,174 

431,  432 
180 
194 

408,  409 
423 
153 
417 
407 
430 
430 
439 
407,  417-427 

376,  377 

268 

321,  428,  429 

427,  428 
428 
407 

416,  417 
416 
430 
383 
303 
58,  129 
160 
162 
69 

380,  382 


415, 


—  469  — 

PAGE 

Cascara  sagrada,  as  a  laxative 153 

Castor  oil  u         n  jgg 

Catarrh,  gastric,  atrophic 58,  159 

"  "  "         diSerential  diagnosis  of     ...         .  58 

"  "        bitters  in 78 

"  "        chronic,  condition  of  mucous  membrane  in  .         .  59 

"  "  "  dyspeptic  symptoms  in      ...         .  59 

"  "  "         silver  nitrate  in 119 

"  "         condurango  in  .         .         .         .         .         .         .         .  .    •    78 

"  "         contents  of  stomach  in  .         .         .         57,59,60,127 

"  "         diet  in,  vide  Food. 

"  "         differential  diagnosis  of 

"  "        Karlsbad  in 

"  "         nux  vomica  in  . 

"  "         prognosis  in       . 

"  "        treatment  of 

"  simple,  of  the  large  intestine,  differentiated  from  tubercu 

lous  ulcerations       .... 

"  of  the  biliary  passage  [vide  Cholangitis) 

Catarrhal  conditions,  contrasted  with  predisposition  to  same,  treat- 
ment of     .....         , 

C^lestins,  vide  Vichy. 

Cerebral  congestion,  derivative  bloodletting  in 

Chapman's  treatment  of  cholera  (foot-note) 

Charcot  on  hepatic  cirrhoses 

Chest,  inquiry  about,  in  examining  a  patient 

Chloranaemia,  treatment  of  ... 

Chlorosis   (17th  case)    . 

"  balneotheraphy  in 

"  Botkin  on    . 

"  causation  of 

"  classification  of 

"  constipation  in 

"  diagnosis  of 

"  hydrotherapy  in 

"  mental  condition,  in  the  causation  of 

I'  nervous  system  in 

prognosis  in         .         .         . 
"  sexual  maturity,  as  related  to 

'*  symptomatology  of    . 

"  treatment  of        .         .         . 

"  Virchow  on  .         .         . 

"  and  hysteria 

"  and  tuberculosis 

Cholangitis  and  biliary  calculi  (6th  case) 

"  and  hypertrophic  venous  cirrhosis  (7th  case) 

"  and  biliary  and  hypertrophic  biliary  cirrhosis  (8th  case) 

Cholelithiasis,  vide  Calculi,  biliary. 


159 
103 

78 
194 
195 

47 
194 

355 


401 
383 
189 
13,14 
261 
248 
257 
251 
252 

250,  251 
256 

249,  250 
257 
251 
257 

253,  254 
252 

248,  249 
254,  255,  256 
251 
253 
261 
166 
182 
193 


—  470 


Cholera 

"       algid  stage  of 

•  "        arrivals,  supervision  of,  in  epidemics    . 
"        attack,  symptoms  of  an  . 
"        causation  of,  according  to  Pettenkofer 

"       contagiousness  of 

"       complications  of      ....         . 

"        Hueppe's  investigations  about 

"        infectiousness  .  .... 

"         immunity  toward,  Pettenkofer's  experiments  concer 

"  "  "        unreliability  of  experimentation 

"        individual  measures  of  precaution  against  . 

"        nature  of  

"        nephritis  of  the  algid  stage 

"         Mcati  (and  Rietsch)  toxine  from  cholera  bacteria 

"        predisposition  to 

"         preventive  measures  against  .... 

"         reaction  stage  of      ......         . 

"         spleen,  condition  of,  in  . 

"         treatment  of  {vide  also  special  headings)  . 

"  "  effectiveness  of  .... 

"  "  necessity  for  systematic  . 

"  "  diarrhoea 

"         nostras 

Cholerine 

"        treatment  of 

Circulation,  as  influenced  by  baths 

Cirrhosis  of  the  liver,  hypertrophic,  biliary 
aetiology  of  . 

differential  diagnosis  of,  from 
amyloid  degeneration 
cancer  ..... 

closure  of  ductus  choledochus  . 
hyperaemia  .... 

multilocular  echinococcus 

syphilis 

prognosis  of  ....  191, 

treatment  {vide  also  Calomel)    . 

varieties  of 

"  clinical      .... 

Climate,  definition  of    .......         . 

"        elements  of     .         .         .         . 

"        nature  of         .         .         .         ... 

"        relation  of,  to  climatotherapy       .... 

"        varieties  of 

"        temperature  of        ......         . 

Climatotherapy,  elements  of:  air,  clearness  of. 
"  •'  "         "    density  of     . 


ning 


PAGE 

357 
365 
371 

304,  365 
359 

362,  363 
384 

301,  302 
359 
362 
362 

371,  372 

357,  358 

366.  367 
366 
359 

371,  372 

367,  368 
367 


372,  373 
373 

375-379 
384 
364 

381,  382 

337 

193,  419,  420 

190 


187 

187,  420 
420,  421 

420 

188,  421 

187,  426 
192,  426,  427 
191,  421,  422 

188,  189 
190 
298 
300 
299 
299 
299 
300 
302 
301 


—  471  — 

Climatotlierapy,  elements  of:  air,  moisture  in    . 
"  "  "   beauty  of  locality 

"   soil 
"  "  "    sunlight 

"  "  "   trip  to  a  sanatorium 

"  "  "    vegetation 

"  "         "   waters    . 

"   winds     . 

"  in  Eussia 

Clinic,  ambulatory 

"       faculty        

"        general,  nature  and  contents  of 

"       hospital      ....... 

"       propaedeutic 

"       special         

"        of  internal  diseases,  vide  General  clinic. 
"       and  medical  education     .... 
"         "     scientific  medicine  .... 
Clinical  assistant,  duties  of  .... 

"        exercises,  influence  of    . 

"  "  division  of,  in  the  course  of  study 

"  "  relation  to  systematic  exposition 

"         professor,  duties  of 
Clyster,  in  constipation 
Cocaine,  in  vomiting  of  cholerine 
Cod-liver  oil  in  tuberculosis 
Codeine  for  intestinal  pains 
Cold  as  a  causative  agency  in  pleurisy 
Colic,  biliary,  causation  of  . 
"       calomel  in 
"      diagnosis  of    . 
"  "  differential 

"  "  "  from  cancer 

"  "  "  "     gastric  diseases,  etc 

ether  in  .... 

symptoms  of  .         .         . 

treatment  of  ... 

warm  baths  in       .         .         . 
Condition  of  patient,  interrogation  about 
Condurango  in  diarrhoea 
Constant  electric  current  in  atonic  gout 
Constipation,  cause  of,  in  gastric  catarrh 
"  laxatives  in    . 

"  in  nervous  dyspepsia    . 

"  treatment  of  . 

Contrex^ville,  chemical  composition  of 
"  contraindication  for  use  of 


PAGE 
301 

303 

302 

301 

303 

302 

302 

302 

307,  308 

4 

4 

4,5,6 

4 

3 

4,5 


265, 
171, 


1,2 

27,  28 

30 

2 

28,29 

2 

28 

152 

381 

294 

124 

266 

175 

410 

172 


76, 


172 

172-175 

179 

117 

180 

177 

10 

78 

222 

67 

153 

150 

151 

93 

80 


152, 


—  472  — 

PAGE 

Contrex^ville  in  atonic  gout 222,  228 

"  in  oxaluria  and  renal  colic  ......  97 

"  in  phosphatic  gravel .         106 

Goto,  tincture  of,  in  diarrhoea .51,  379 

Cough  in  pneumonia,  treatment  of 321,  322 

Cramps  in  cholerine,  treatment  of       ......         .         382 

Creosote  compared  with  koumyss  in  pulmonary  tuberculosis  .         293 

"        introduction  of ,  through  respiratory  tract  .         .         .         297 

"        in  tuberculosis 295,  296,  315 

"        in  septictema  and  pysemia      .......         464 

"        subcutaneous  injections  of  .         .         .         .         .         .    •     .         296 

Cupping-glasses,  care  in  application  of,  for  apoplexy         .         .         .        395 

"  diseases  in  which  employed 393 

"  effects  of  application        .         .         .         .         .         394,  395 

"  methods  of  application 395 

"  number  of 394 

"  reasons  for  preferi'ing  them  to  leeches  .         .         .         394 

Davos  compared  with  other  sanatoria 306,  307 

Debout  d'Estr^es  on  the  former  use  of  mineral  waters      .         .         .         108 
Deficiencies  in  students'  knowledge,  making  up  of  ...         .  26 

Diabetes  mellitus,  relation  of,  to  oxaluria  .....  54 

Diagnosis  segri 18 

•'  morbi 18 

"  differential    ..........  18 

"  how  arrived  at 15,  18,  42 

Diaphoretics  in  pleurisy 267,  269 

Diarrhoea,  cold  in 51 

"  Ems  water  in        ........         .  94 

"  opium  in       .........         .  51 

"  wine  in  ..........  43 

"  prevalence  of,  during  an  epidemic  of  cholera  .         .         .         375 

"  choleraic,  treatment  of  (vide  separate  headings)      .  376-381 

Diet  {vide  also  Food). 

"     during  the  administration  of  arsenic  in  ana3mia         .         .         .         256 

"     in  gastric  catarrh  ..........         150 

"     in  nervous  dyspepsia 149,  150 

Diseases,  infectious,  former  classification  of       ....         .         358 

Distention  of  the  stomach .  60 

Disinfection  in  the  prevention  of  cholera  outbreaks  .         .         .         370 

Diuretics  in  pleurisy 267,  269 

Douches  in  nervous  dyspepsia 151 

Dover's  powder  in  pleurisy  .         .         .         .         .         .         .         .         .         208 

"  "         in  pneumonia      ........         322 

Dyspepsia,  baths  in       .........         .        151 

"  constipation  in   .         .         .         .         .         .         .         .         .         150 

diet  in 144,  150 

"  Ems  water  in 151 


—  473  — 

Dyspepsia,  erroneous  employment  of  lavage  in 

"  mineral  waters  in       .         .         . 

"  nervous,  gastric  symptoms  of  . 

"  "  diagnosis,  differential 

"  nux  vomica  in     . 

"  silver  nitrate  in  . 

"  varieties  of  (gastric,  nervous)    . 

Dyspeptic  symptoms,  preliminary  treatment  of 
Dyspnoea  in  pneumonia,  treatment  of 


tract 


Ebstein  on  gout 

Echinococcus  cyst  of  the  liver  (9th  case)     . 
Effusion  in  pleurisy,  absorption  of 
"  "  character  of 

"  "  operative  removal  of , 

Eichhorst,  treatment  of  pleurisy 

"  on  hsemon'hoids  .... 

Electricity  in  neurasthenia  .... 
Emmerich's  experiments  on  cholera    . 
Ems,  chemical  composition  of      . 
"      compared  with  Marienbad  . 
"  "  "     Obersalzbrunnen 

"      dosage  of       .         .         .         .         . 
*'      indication  for  use  of     . 
"      in  biliary  calculi  ..... 
"      in  catarrhal  conditions  of  the  respiratory 
in  gout  (atonic)     ..... 
in  oxalic  acid  gravel    .... 
in  pulmonary  tuberculosis 
washing  of  the  stomach  with 
with  sodium  iodide      .... 

"  salycilate 

Kesselbrunnen      ..... 
"  compared  to  Kranchen 

"  in  nervous  dyspepsia 

"  in  hypertrophic  biliary  cirrhosis 

Kranchen       

Enteroclysmata  in  choleraic  diarrhoea 
Ergot  (secale  cornutum)  in  haemoptysis 
Erysipelas,  facial,  calomel  in 
"  quinine  in 

Ether  in  the  algid  stage  of  cholera 
"      in  biliary  colic      .... 
in  vomiting  of  cholerine 
Eucalyptus  oil  in  tuberculosis 
Examination,  objective 

"  "  conduct  of 

"  '*  notes  on 

'■  '■  tact  requisite 


,  in  tuberculosis 


57, 


PAGE 

136 
117 
127,  158,  159 
158 
151 
151 
149 
296 
321,  322 


213 
197 
269 
265,  266 
269 
267 


147 

362 
93 

101 
)6,  97 
HI,  112 
94 
79 
)6,  97 
222 
79 
97 
124 
208,  456 
210 
130,  131 
96 
151 
425 


380,  381 
291 
427,  428 
427 
383 
179 
381 
297 
17 
17 
325 
18 


—  474  — 

Febrile  condition,  inquiry  about,  in  examining  a  patient 

Fever,  hectic,  in  pulmonary  phthisis 

"  "  "  cause  of    .        .        . 

"  "  "  treatment  of     . 

"  "  "  undesirability  of  bringing 

down  to  the  normal 
"       a  protecting  agency  to  the  organism 

"       treatment  of 

Finkler-Pryor,  bacillus  of  cholera  nostras 
Food,  artificial,  use  of  .... 

"       in  chronic  gastric  catarrh 

"  '•  '  "         quality  of 

"  "  "  "        quantity  and  apportionment  of 

"  "  "  ■'        instructions  to  patients  about 

'■  "  "        variation. 

Fragaria  vesca  (strawberry)  in  atonic  gout 
Frankel  on  phthisical  stage  of  tuberculosis  (foot-note) 
Franzensbad  water,  chemical  composition  of 

"  "       diseases  in  which  it  is  used 

"  "       (Salzquelle)  Moorbader 

"  "        temperature  of     . 

"  "  for  use 

Frerich's  case  of  hepatalgia 

Friedrichshall,  chemical  composition  of     . 


it 


Gastein,  an  Austrian  watering-place 

Gastric  splash,  unreliability  of,  as  a  symptom  . 

"       lavage,  abuse  of 61,  62,  63, 

"        sound  in  differential  diagnosis  of  diseases  of  the  stomach 
Genital  organs,  male,  inquiry  about,  in  examination  of  patient 

Gmunden,  an  Austrian  watering-place 

Gorbersdorf  compared  to  Davos 

"  as  a  climatotherapeutic  sanatorium 

Gout,  atonic  (12th  case) 221 

"      causation  of        .........         .        213 

differentiation  from  nocturnal  syphilitic  pains        .         .         .        227 
"       milk  treatment  in       ........         .         236 

"      predisposition  to .         .         221 

"      relation  of,  to  acute  articular  rheumatism       .         .         .        213,  214 

"  "  to  articular  diseases 221 

"      strawberry  tea  in .         .         .        236 

"       symptoms  of 214,  226 

"      treatment  of 222,  228,  229 

"      Vichy  water  in 104 

Grande-Grille,  vide  Vichy. 

Gravel,  oxalic  acid,  Ems  in 79 

.     "  "  Contrex^ville  in 80 

"       phosphatic,  Contrex^ville  in  .         .         .         1         .         .         .        106 


PAGE 

14 

285 
286 
292 


292 

460 

460 

384 

85 

75 

77 

75 

76 

77 

236 

286 

93 

104 

143,  345 

95 

115 

173 

93 

340 

60 

132,  137 

63,  64 

32 

344 

306,  307 

305 


—  •475  — 

Guaiacol  and  its  carbonate  in  pyaemia  and  septicaemia     . 
"  ''  "  in  tuberculosis 

"  carbonate  in  incipient  tuberculosis 

Gumma,  syphilitic,  of  the  liver,  differential  diagnosis  of 


PAGE 

464 
295.  296,  314 
262 
164 


H^MATix  in  ulcer  of  the  stomach 127 

Hsematopoiesis,  balneotherapy  in  diseases  of    .         .         .        .         .        354 
Haemoptysis  in  tuberculosis,  bloodletting  in      ...         .        403,  404 

"  "  leeches  in 292 

treatment  of.         .         .         .  291,292,403 

Haemorrhoids,  case  of,  substantiating  author's  views  on .         .         .        397 

"  causation  of 398 

former  views  on    .      * 396 

"  nature  of  (an  angioneurosis) 397 

"  pure,  uncomplicated 397 

"  views  concerning ........         397 

Hamburg,  epidemic  of  cholera  in,  origin  of       .         .         .         .         .        360 

Hahnemann  in  the  history  of  therapeutics        .....  23 

Hanot  on  hepatic  cirrhoses 189 

Headache,  inquiry  about,  in  examining  a  patient     ....    15,  16 

Heart,  determination  of  dimensions  of 329,  330 

"       diseases  of,  balneotherapy  in 353 

"  "  milk  treatment  of  ......         455 

"       syphilis  of  the,  angina  pectoris  in 448,  449 

"  "  "        diagnostic  data  of 454 

"  "        lack  of  knowledge  on 447 

"  '*        treatment  of 454 

'■        type  of  the  majority  of  cases  .         .         .        449 

varieties  of  cases 449 

Helouan,  a  health  resort  near  Cairo,  Egypt 303 

Hepatalgia,  relation  of,  to  biliary  calculi  ....  171,  173,  174 

"  Frerich's  case  of I73 

Horseback  riding  as  a  predisposing  factor  in  haemorrhoids      .         .         398 

Hospital  therapy,  characteristics  of 25 

Hueppe's  investigations  on  cholera 359,360,361,362 

"  toxine  of  cholera  bacteria 366 

"  use  of  bismuth  phenolate  in  cholera  ....        377 

Hydrobilirubin,  formation  of  (foot-note)     .         .         .         .         .         .         253 

Hydrotherapy,  effects  of 348 

general 348,  349 

"  local 349 

methods  of  application 347,  348 

in  chlorosis 257 

in  neurasthenia 146,  148 

Hygiene  in  the  treatment  of  neurasthenia 145 

"  ■'  "  pleurisy 270 

•'         neglect  of,  in  modern  therapy 23,  24 

Hyperaemia  of  infectious  diseases,  bloodletting  in    .         .         .         .         402 


—  476 


Hypersemia  of  the  spinal  cord  and  its  membranes,  bloodletting  in,  402,  403 
Hypodermoclysis  in  choleraic  diarrhoea     .         .         .         .         ....      380 

"  in  the  algid  stage  of  cholera  proper      .         .         .        382 

Hysteria,  balneotherapy  in 350 

"  carbonated  waters  in    .         .         .         .         .         .         .        344,  345 

"  sea-bathing  in 347 

"  and  chlorosis 253 


Ice  in  the  vomiting  of  cholerine  .... 

Impotence,  male,  hydrotherapy  in      . 
Individualization  in  clinical  vrork       .... 
Infectious  diseases,  former  classification  of 
"  "  treatment  of  fever  in  . 

Influences,  effect  of  mechanical,  in  hydrotherapy     . 
Interrogation  of  patient,  special  points  about    . 
Intestines,  particular  inquiry  about  the  condition  of 

Investigation,  objective 

Iodides  in  syphilitic  affections  of  the  heart 

liver 
Iodine  in  the  treatment  of  pleurisy     .... 

Ipecac  in  cough 

"              "        of  pneumonia,  erroneous  administration 
Iron  in  chlorosis 

"     in  neurasthenia     ....... 

"     mineral  waters  in  chlorosis  .... 

"     sulphate,  effect  of,  in  hydrotherapy   . 
Ischias  ex  neuritide  (sciatica),  bloodletting  in 
Ischl,  an  Austrian  watering-place       .... 


of 


381 

352 

3 

358 
460,  461 

339 

8,  9,  10 

.  10,  11 

17 

448,  457 

206 
267,  269 
276,  279 

322 
254,  255,  256 

147 

256 

339 
393,  395 

344 


JuERGENSEN  on  bloodletting 
Jaundice,  catarrhal 

"  "  calomel  in 


Karlsbad,  chemical  composition  of 

"  compared  with  Ems 

"  (MUhlbrunnen)  compared  with  Marienbad 

"  in  cholelithiasis 

"  in  gastric  catarrh 

"  in  renal  gravel 

"  with  "  Karlsbad"  salt 

"  mode  of  administration 

Keffir  in  tuberculosis    . 
Kesselbrunnen,  vide  Ems. 

Kidney,  movable  (for  diseases  of,  vide  Nephritis) 
Kissingen,  chemical  composition  of    . 
"  compared  with  Marienbad 

"  contraindications  to  use  of 


95, 
102, 
167,  176, 


388 

432,  433 

430 


93 
103,  177 
103,  187 
177,  179 
103 
105 
104 
177 
294 


69,  70 

93 

103 

95 


ulosis  (foot-note) 


—  477 

Kissin^en,  dosage  of      . 

"  temperature  of     . 

Koch  on  "  contagiousness"  of  cholera 

"      on  the  "  streptococcencurve" 
Koumyss  in  neurasthenia     . 

"  in  tuberculosis 

Kranchen,  vide  Ems. 
Kreutznach,  a  German  watering-place 

L^NJJ^EC,  atrophic  cirrhosis  of  the  liver 
Lamanche,  a  trip  to.  in  neurasthenia 
Lavage,  gastric,  employment  of 

"  "  "  failures  in 

Laxatives  in  constipation     . 

"  in  pleurisy    .... 

Leeches  in  pulmonary  haemoptysis 
'■        in  reaction  stage  of  cholera    . 
"        for  depletive  bloodletting 
Leucocytes  in  the  gastric  contents 
Leuk,  a  watering-place  in  Switzerland 
Leyden  on  the  phthisical  period  of  tuberc 
Liquor  ammonise  anisatus    . 
Lithium  in  gouty  pains 
Liver,  blood-stasis  of,  bloodletting  in 

"       cirrhosis  of,  vide  Cirrhosis. 

"       determination  of  dimensions  of 

"       echinococcus  of  (9th  case). 

"       syphilitic  affection  of 

"  "  "  prognosis  of 

*'  "  "  treatment  of 

"       torpor  of,  calomel  in  . 
Lungs,  syphilis  of  the  .... 

"  ''  "       cases  of    . 

"  "  "       diagnostic  data  about 

"  "  "        treatment  of     . 

"  ■'  "       tuberculosis  in  syphilitics 

*'  '      tuberculosis  of,  vide  Tuberculosis. 


Madeira  wine,  in  the  etiology  of  the  case  of  biliary  cirrhosis 
Madeiras,  the,  as  health  resorts  . 
.Magnesia  usta  for  pyrosis     .... 

"  "     as  a  laxative 

Marienbad  water,  chemical  composition  of 
"  "        compared  with  Ems 

Karlsbad 

Kissingen 

Vichy    . 

Yessentucki 


PAGE 

113 
115 
361 
286 
292 
292,  293,  294 

344 


437- 


330 

101 

1.32 

133 

134,  135 

136 

152, 

153 

267, 

269 

292 

383 

393 

127 

340 

286 

279 

229 

404 

330 

197 

204 

205 

206, 

208 

409, 

410 

436 

-440,  441-444 

441, 

444 

445 

437 

3 

426 

304 

124 

152 

93 

101 

102, 

103 

103 

102,  104, 

105 

105, 

106 

—  478  — 

Marienbad  water,  contraindications  for  use  of 
"  "       dosage  of         .         .         . 

•     "  '■        drinking,  method  of 

"  "       in  gastric  cataiTh    . 

'*  "       repeated  use  of 

"  "       temperature  of,  when  admin 

"  "       types  of  patients  for  treatment  with 

"  trip  to,  in  connection  with  the  drinking  of  th 

Massage,  general,  effects  of  .         .         . 


istered 


e  water 


in  Dr.  S.  W.  Mitchell's  treatment  of  neurasthenia,  53,  54 


"  "        in  atonic  gout 

"  ''         in  muscular  rheumatism 

"  "in  neurasthenia 

Meat-powder,  use  of,  in  gastric  disorders  . 
Menstruation,  relation  of,  to  hsemorrhoidal  bleeding 
Menthol  in  tuberculosis         ..... 
Mentone,  a  health  resort  in  Southern  France     . 
Mercurial  inunctions  in  syphilis  of  the  liver 
Metallic  poisoning,  hydrotherapy  in  . 
Method  requisite  in  clinical  work 
Miasmatic  diseases,  nature  of      . 

"  contagious  diseases     .... 

Milk  treatment  in  atonic  gout     .... 
"  "  in  diseases  of  the  heart 

"      as  a  diuretic 

Mitchell's,  Dr.  S.  W.,  treatment  of  neurasthenia 
Morphine  in  pleurisy    ...... 

"  in  the  vomiting  of  cholerine 

Moschus  in  the  reaction  period  of  cholera 
Moscow  practice  of  bloodletting  .         .         . 
Muds,  mineral,  use  of  . 
Miihlbrunnen,  vide  Karlsbad. 
Murmur,  bronchial  respiratory,  as  a  symptom  . 

"  indefinite  "  "  " 

"         vesicular  "  •'  " 

Myocarditis,  syphilitic,  case  of    . 
Myositis,  chronic,  hydrotherapy  in 


Naecotics,  care  in  using,  in  pneumonia 
Narzan,  a  Russian  watering-place 
Nephritis,  acute,  bloodletting  in 
*'  "       calomel  in 

"  chronic,  baths  in 

"  .    "         prognosis  of 

"  "         treatment  of. 

"  "         varieties  of 

"  interstitial,  course  of 

"  "  diagnosis  of 


PAGE 

94,  95 
113 
101 
103 
102 
116 
100,  101 
101 
54 


303, 


222 
223 
146,  147 
85 
398 
297 
314,  315 
263,  268 
354 
3 
358 
358 
236 
455 
246,  455 
53,  54 
268 
381 
383 
388,  389 
345,  346 

326 

327 
327 

447,  448 
354 


322,  323 
344 
393 
429' 
352 
243,  244 
246,  247 
242 
243 
244 


—  479  — 

Nephritis,  interstitial,  senile 
"  parenchymatous 

"  "  course  of 

"  "  diagnosis  of     . 

Nephrolithiasis,  warm  baths  in  {vide  also  Biliary  calculi) 
Nerves,  cardiac,  syphilitic  affection  of,  cases 
Nervous  system,  condition  of,  in  chlorosis 
Neurasthenia,  arsenic  in       .         .         . 
"  balneotherapy  in  . 

carbonated  waters  in    . 
characteristic  features  of 
diet  in    . 
electricity  in 
etiology  of     . 
Franzensbad-Salzquelle  in 
gastro-intestinal,  hydrotherapy  in 

"  varieties  of 

hydrotherapy  in    . 
hygiene  in      . 

iron  in  .... 

koumyss  in    . 
massage  in     . 
"  Mitchell's  treatment  of 

"  prognosis  of  . 

'*  sea-bathing  in        .         .         . 

"  sexual  intercourse,  immoderate,  as  a  causative 

cy,  treatment  of 
"  silver  nitrate  in     . 

"  treatment  of,  radical 

"  trips  to  various  seashores  for 

Neuritis,  treatment  of,  in  articular  rheumatism 
Mcati  (and  Eietsch),  cultures  of  choleraic  toxine 
Nice,  a  health  resort  in  Southern  France    . 
Noorden,  v.,  on  the  formation  of  hydrobilirubin  (foot-note) 
Nothnagel  (and  Rossbach)  on  the  use  of  calomel  in  Germany 
Nussbaum's  cells  in  chronic  gastric  catarrh 
Nutrition,  balneotherapy  in  diseases  of 

"  importance  of,  in  tuberculosis   . 

Nux  vomica  in  gastric  catarrh 
"  in  nervous  dyspepsia 


ObeSitt,  general,  milk  treatment  in  . 

Obersalzbrunnen,  chemical  composition  of 
"  compared  with  Ems 

"  dosage  of  .         .         . 

"  use  of       ...         . 

*'  in  pulmonary  tuberculosis 

"  with  milk  (for  cough)     . 


agen- 


PAGE 

158 
243 
244 
245 
352 
448 
257 
147 

350,  351 

344,  345 
71 

149,  150 
147 
144 
104 
362 
149 

146,  148 
145 
147 
293 

146,  147 
53 
146 
347 

145,  146 
147 
148 
101 
223 
365 
305 
253 
407 

59 
354 
292 

79 
151 


455 
93 
96 
111 
96,  97 
96,  97 
275,  279,  310,  314 


—    480  — 

Observation  of  the  course  of  the  disease     . 

"  neglect  of 

(Edema  of  the  lungs,  bloodletting  in  . 

"  "  "        rales  in        .         .         . 

Odessa  estuary,  a  health  resort  . 
Oleum  terebenthinse  rectif .  in  tuberculosis 
Opium  in  choleraic  diarrhoea 

"       in  intestinal  pains    .... 

"       reasons  for  employing 
Oxalic  acid  gravel,  vide  Gravel. 

"  "     sediment  in  relation  to  uric  acid  during  treatment 

Oxaluria,  Contrex^ville  in   . 

"  relation  to  diabetes  mellitus 

*'  as  a  symptom 

Oxaluric  patient,  characteristics  of     . 


Pains  in  pneumonia,  treatment  of 
Pancreas,  cancer  of  (5th  case) 

"  "  absence  of  symptoms  of 

"  "         diagnosis,  differential 

Pepsin,  condition  of,  in  chronic  gastric  catarrh 

"        use  of,  in  diseases  of  the  stomach  . 
Percussion  sound,  varieties  of      . 
Pericarditis,  blisters  in  .... 

Pericystitis,  leeches  in 

Perihepatitis,  syphilitic         .         .         . 
Peritoneal  inflammation,  hydrotherapy  in 
Peritonitis,  leeches  in  . 
Peruvian  balsam  in  tuberculosis 
Phenacetine  in  hectic  fever 

"  in  pleurisy        .... 

"  in  pneumonia  .... 

"  in  reaction  stage  of  cholera     . 

Phthisis  declarata  (pulmonary  phthisis),  appearance  of 

"        care  of 

"         galloping  ..... 

"  .       hectic  fever  in  .... 

"         mixed  infection  in  .         .         . 

Pilocarpine  hydrochlorate  in  pleurisy 
Piperazine  in  gouty  deposits 
Pityriasis  versicolor  in  emaciated  persons 
Pleurisy,  acute  {19th  case,  with  tuberculosis) 

"  bloodletting  in       ...         . 

"■         breaking  up  of  the  acute  stage  of 

"         causation  of 

"  "  cold  as  a  factor  in  the 

''         compressed  air  in  . 

"  differentiated  from  pneumonia   . 


PAGE 

.    25,  26 

26 

393 

328 

343,  344 
297 

377,  378 
.    50,  51 

378,  379 


235 
54 
70 


321,  322 

162 

169,  160,  164 

164 

69 


329 
393 
396 
204 
352 
396 
297 
268 
268 

320,  321 
383 

patients  with,  285 
288 
289 
285 
286 
267 

229,  230 

.  45,  46 

263 

268,  393,  394 

267 

265 

265,  266 

272 

265,  318,  319 


—   481 


PAGK 

270 

266 

264,  265,  267 

, 267,  268,  269,  270 

270 

267 

268 

267 

267 

268 

265,  266 

269,  270 

893,  394 


ulmonary 


428, 


Pleurisy,  hygiene  in 

prognosis  of   . 

symptoms  and  physical  signs  of 
treatment  of  (vide  drugs  under  special  headings 
"  "ambulance"   .... 

"  Eichhorst's        .... 

"  fever  .         .     '    . 

"  in  syphilitic  patients 

"  in  tuberculous  patients    . 

"  pain 

with  effusion,  determination  of  character  of 
"  operative  removal  of     . 

Pleuropneumonia,  acute,  bloodletting  in    . 
Plombiferes,  a  French  health  resort     .... 
Pneumonia,  catarrhal  (caseous),  complicating  chronic  j 

tuberculosis 

croupous  (fibrinous),  bloodletting  in 
"  calomel  in         ...         . 

"  case  of (22d  case) 

"  complicating  chronic  pulmonary  tuberculosis, 

'*  dangerous  symptoms  in 

"  diagnosis  of 

"  prognosis  of 

"  rales  in      . 

syphilitic,  case  of    . 

"  diagnostic  data  on 

"  treatment  of  . 

temperature  of,  treatment  of 
treatment  of  {vide  drugs  under  separate  headings), 

Podophyllin  as  a  laxative 

Polyarthritis  chronica  (chronic  articular  rheumatism) 

Popoff,  Dr.  P.  M.,  on  gastric  catarrh  .... 

Potassium  chlorate,  gargling  with  a  solution  of,  when  using  calomel, 

"  tartrate  as  a  laxative 

Predisposition,  individual,  to  cholera 
Preventive  measures  against  cholera  . 
Prognosis,  definition  of         .         .         . 
"  physician's  duty  concerning 

"  precision  in  wording  the 

"  as  regards  the  patient 

"  "         the  patient's  relatives 

":_  in  extreme  cases 

Piillna  spring  (Bitterwasser),  chemical  composition  of 
Pulse,  condition  of,  when  employing  venesection  for  apo 
"       importance  of,  in  objective  examinations 
"       qualities  of  ...... 

Pyatigorsk  springs,  chemical  composition  of 


340 


287 
393 
429 
317 
286 
320 

318,  319 
319 
328 
441 
441 
445 

320,  321 
319-323 
153 
221 
57,  59,  84 
417 
152 


482 


Quarantining  along  the  Asiatic  borders  during  cholera  epidemics,      369 


"  impossibility  of  a  thorough  application  of 

Quinine,  a  "  pseudo  "  preventive  measure  in  cholera 

"  compared  v^ith  sodium  salicylate 

"  in  erysipelas  . 

"  in  feverish  conditions    ■ 

"  in  hectic  fever 

"  in  pleurisy 

"  in  pneumonia 

Ragatz,  a  health  resort  in  Svpitzerland 

Rakoczy,  vide  Kissingen. 

Rales,  respiratory,  importance  of         .         .         . 
"  "  varieties  of     . 

Reaction  period  of  cholera  ..... 
"  in  hydrotherapy,  significance  of 

Rehme-Oeynhausen,  an  artesian  spring  in  Prussia 

Reichenhall,  a  German  watering-place 

Remedies,  simultaneous  employment  of     . 

Respiration  as  influenced  by  baths 

Respiratory  organs,  balneotherapy  in  diseases  of 

Rhamnus  frangula  (black  dogwood)  as  a  laxative 

Rheumatism,  acute  articular  (11th  case)    . 

"  "an  infectious  disease 

"  "  autipyrine  in 

"  "  predisposing  conditions  to 

"  "  relation  of,  to  gout 

''  "  sodium  salicylate  in 

"  chronic  (12th  case) 

"  '•         anatomical  investigation  of 

■'  "         etiological  factors  in 

"  "         incorrectness  of  terra  of 

"  "         polyarthritis  chronica 

"  "         predisposing  factors  to 

"  "        relation  of,  to  acute 

"  "        treatment  of 

Rhubarb,  powdered,  as  a  laxative 

Riviera,  Italian  health  resorts  on  the  Mediterranean  shore 

Russian  bath  ......... 


368 
372 
268,  269 
427 
463 
292 
268 
320 

340 

328 
328,  329 
367,  368 
347,  348 
345 
344 
24 
337 
353 
153 
209 
212 
212 
210 
213,  214 
210,  211 
215 
219,  220 
219,  220 
212,  217,  218 
221 
221 
218 
222,  223 
152 
303 
349,  350 


Saki,  a  health  resort  in  Southern  Russia,  compared  with  Franzens- 


bad 

Salicylic  acid  in  pleurisy      .         .         .         . 

Salol  as  an  anticholeraic  remedy         ..... 

Salt,  common,  percentage  of,  in  salt  baths 

Salts,  laxative,  contained  in  the  mineral  waters,  effects  of 

Sanatoria,  trips  to,  with  climatotherapeutic  aims  in  view 

San  Remo,  an  Italian  health  resort     ..... 


341,  342 
267 
317 
344 
91 
316 
303 


488 


Schlangenbad,  a  Prussian  watering-place  . 
Schwalbacli,  a  Prussian  watering-place 

Scrofula,  hydrotherapy  in 

"         sea-bathing  in 

Semiatalectesis  of  the  lungs,  physical  symptoms  of 

Senna  as  a  laxative 

S^vignd,  Mme.,  treated  at  Vichy         .         .         .         . 


328, 


Sexual  intercourse,  immoderate,  as  a  causative  factor  in  neurasthenia,  145 


268, 


"       maturity  in  relation  to  chlorosis 

Shift's  theory  regarding  the  effects  of  calomel  .... 
Shkliareffsky's  treatment  of  the  algid  stage  of  cholera  (foot-note) 
Silver  nitrate  in  gastro-intestinal  catarrh  ....  118, 

"  "        in  nervous  dyspepsia 

"  "        in  neurasthenia 

Skin,  diseases  of,  hydrotherapy  in 
Slavyansk,  a  Russian  watering-place 
Soden,  a  German  watering-place 
Sodium  bicarbonate,  action  of  in  the  body 

"  "  "         in  external  application 

"  "  "         in  washing  the  stomach  with 

"        chloride,  action  of  in  the  body 

"  "  "         in  external  application 

"        compounds  in  catarrhal  conditions  of  the  stomach 

*'        salicylate  compared  with  quinine  . 

"  "  in  acute  articular  rheumatism 

"  "  in  atonic  gout 

"  "  in  hectic  fever 

**  "  in  pleurisy       .... 

"        sulphate  (Glauber's  salt)  as  a  laxative  . 
Soil,  importance  of  (vide  Climatotherapy) 
SokolofE's  theory  on  the  effect  of  calomel  . 
Sound,  gastric,  use  of,  for  diagnostic  purposes  . 

''  "  "       objections  to,  for  purposes  of  verification 

Spanish  flies  in  dyspnoea  of  pneumonia 

"  "in  angina  pectoris  .... 

Specific,  the  nature  of  a        . 
Spinal  cord,  diseases  of,  balneotherapy  in 

"  "  "  bloodletting  in 

Splash,  gastric,  as  a  symptom      .... 
Spleen,  changes  of,  in  cholera      .... 

"         determination  of  dimensions  of 

"         hypersemia  of,  hydrotherapy  in 
Sputum,  examination  of,  in  pneumonia 
Stara-Russa,  a  Russian  resort       .... 
Status  prsesens,  definition  of         ...         • 
Stimulants,  habitual,  result  of  enforced  abstinence 
"  "  use  of         ...         . 

"  in  pleurisy  ..... 


from 


PAGE 

340 

344 
347 
354 
329 
153 
108 


252 
409 
383 

119,  120 

151 

147 

354 

344 

344 

90,  91 

338 

124 

90,  91 

338 

86 

269 

210,  211 
222 
292 

270,  271 

152 

302 

409 

63,  64,  65,  66 

77 

322,  323 
456 

290,  291 
352 

402,  403 
128 
367 
330 
352 
319 
344 


268, 


74 

74 

270 


—  484  — 

Stomach,  atrophic  catarrh  of,  vide  Catarrh,  atrophic. 
"  dilatation  of.  causation        .... 

"  lavage  in         .         .         .         . 

"  "  symptoms  of  . 

'•  "  treatment  of  . 

distention  of,  distinguished  from  dilatation 

ulcer  of  (2d  case) 

"        differential  diagnosis  of 
•'  "        symptoms  of    . 

"       treatment         .         .         .         .         . 
Strawberry  tea  (fragaria  vesca)  in  atonic  gout    . 
"  Streptococcencurve"  in  phthisis       .         .         .         . 
Sunlight,  effect  of,  vide  Climatotherapy. 
Sulphur,  action  of,  in  hydrotherapy  .... 
Symptoms,  importance  of,  in  semiotics  and  diagnosis 
Syphilitic  pains  differentiated  from  gouty 
Syphilis,  exclusion  of,  by  negative  symptoms    . 

"  hydrotherapy  in 

"  inquiry  about,  when  examining  a  patient . 

"  of  the  heart  (vide  also  Heart) 

''  "       lungs  (vide  Lungs)      .... 


PAGE 


Tabes  dorsalis  (locomotor  ataxia),  carbonated  waters  in 
Tamponade  of  the  nasal  cavity  for  nosebleed,  care  in  employing 

Tannin  in  diarrhoea 

"  "  of  cholera 

Tea  as  a  stimulant  drink  in  diarrhoea 
Temperature,  influence  of,  vide  Climatotherapy. 
"  of  the  body  as  influenced  by  baths 

"  of  croupous  pneumonia,  treatment  of 

{Vide  also  Fever.) 
Teplitz,  a  health  resort  in  Bohemia    .... 

Terpine  hydrate  for  cough 

Therapy,  hospital,  character  of  . 

"  special    ........ 

Tinnitus  aurium  while  employing  sodium  salicylate 

Tissue  metabolism  as  influenced  by  baths 

Toxine  of  choleraic  bacteria  (Mcati  and  Rietsch,  Hueppe) 

"  "  "its  effect  on  the  system 

Treatment,  employment  of  many  remedies  in    . 

"  individualization  and  method  requisite  in 

"  hospital  methods  of 

"  hygienic,  neglect  of  . 

"  necessity  for  conducting  before  the  students 

"  symptomatic,  abuse  of      ...         . 

■'Trial"  breakfast         ....... 

"  dinner      ........ 

Tribromphenolbismuth  (bismuth  phenolate)  as  an  anticholeraic 


128, 


127, 


129 
133 
128 
131 
60 
122 
.58,  129 
127 
131 
236 
286 


339 

325,  326 

226,  227 

56,  267 

354 

12 

446 

436 


845 

400 

51 

374 

74,  75 

335,  336 
320,  321 


340 

279,  283 
25 
25,  29 
211 
336,  337 
365 
366,  367 
24 
22 
25 
23 
42 
149 
61 
61 
377 


148, 


—  485  — 

PAOB 

Trips  to  health  resorts  with  climatotherapeutic  aims  in  view  .        .        316 

Trypsin  in  diseases  of  the  stomach 84 

Tscherbakofi's  table  of  mineral  waters 92,  93 

Tuberculosis,  acute  miliary,  complicating  chronic    ....        288 

"  chronic  pulmonary 274-278,  309-316 

'*  complications  of    .         .         .        .         .         .         .         .        288 

creosote  in 271,  272,  295,  296,  297 

"  diagnosis  of  chronic  pulmonary ....         283,  284 

"  guaiacol  and  guaiacol  carbonate  in     .         .  295,  296,  297 

"  hjemoptysis  in  the  incipient  stage  of  .         .         .         .        260 

"  how  the  lungs  become  affected  by       .         .         .         .        277 

"  Obersalzbrunnen  in 96,  97 

"  pneumonise  complicating  chronic  pulmonary,     286,  287,  288 

'•  prognosis  of  chronic  pulmonary  ....         289,  290 

treatment  of 290,  316 

"  "  climatic  (vide  Climatotherapy)        .  303-316 

"  "  symptomatic  {vide  Ergot,  KefSr,  Kou- 

myss,  Creosote,  Guaiacol,  etc.)  .         .        291 
"  types  of  persons  affected  by  ....        288,  289 

varieties  of  chronic  pulmonary    .....         283 

Tuberculous  ulcerations  of  the  intestines  ......  48 

Typhoid  cholera,  vide  Reaction  period  of  cholera. 

"        fever,  body  compress  in 462 

*'       calomel  in 420 

Ulcer,  gastric,  vide  Stomach,  ulcer  of. 

Urethritis  a  causative  agency  in  neurasthenia 144 

Uric  acid  diathesis,  vide  Gout. 

Urobilin  (foot-note) 253 

Vegetation,  importance  of,  vide  Climatotherapy. 

Venesection  in  disturbances  of  cerebral  circulation  .         .         .        391,  392 

"  "  circulation  within  the  chest     .         392,  393 

{Vide  also  Bloodletting.) 

Ventricle,  left,  condition  of,  in  interstitial  nephritis        .         .        .        242 

"  "  "  in  parenchymatous  nephritis       .         .        242 

Vertigo,  inquiry  about,  in  examining  a  patient         ....  16 

Vichy,  chemical  composition  of 93 

as  compared  with  Marienbad 102 

C^lestins 95,  102 

"  with  sodium  salicylate 210 

dosage  of Ill 

Grande  Grille 95,  102 

indications  for 104 

in  gout 228 

Virchow's  influence  on  therapeutics 213 

"  views  on  chlorosis        ........         251 

Volga  and  Oural,  koumyss  sanatoria  on      .....         .         294 


—  486  — 
Vomiting  of  cholerine,  treatment  of  . 


PAGE 

381,  382 


Watee,  action  of  ... 

"         drinking,  at  a  sanatorium 
"  "         use  of  in  cholera 

"         mineral,  temperature  of 
Watering-places,  trips  to,  as  a  remedial  agency 
Waters,  mineral,  aims  in  employment  of   .         .         .         .  Ill,  112, 

"         alkaline     ..... 
"         artificial,  compared  with  natural 
"  "         classes  of  (in  balneotherapy) : 

"■  ■•  carbonated 

•'  "  containing  also  salt  . 

•'  chemically  indifferent       ....  340- 

"  muds,  mineral  ......         345, 

salt 343, 

"■  ■'         contraindications  to  use  of      ....         116, 

'•    '     diet  while  employing       .         .         .         .         .         115, 

"•  "         effect  of,  on  the  mucous  membranes      .         .         Ill, 

"■  •'  "         in  the  external  and  internal  use  of 

'■  "  "         the  component  parts  of:  carbonic  acid  . 

"  "  "  "  "  organic  acids  . 

"  "  "  sodium  carbonate, 

"•  ••  "  "  "  "    chloride,  338, 

"■  "  "  "  "  sulphur    . 

"■  '•  "         mechanical  influences  during  external  use, 

'^  "  "         temperature  of,  on  the  circulation  .         337, 

''  '"  "  "  "        nervous  system,  334, 

'■  "  "  "  "        secretions    . 

"•  "  "  "  "       temperature  of  body, 

"  "  ■'       tissue  metabolism, 

"  "        curative  agencies  in        ...         . 

"■  ■'         empiricism  in  the  employment  of  . 

"■  ••         employment  of,  former    .         .         '.  . 

"  "  "  at  the  present  time       .    88, 

"  "         foreign      ....... 

"  ■'         individualization  necessary  in  prescribing 

in  constipation  and  in  diarrhoea     . 
''  •'         length  of  course  of  treatment  with 

"  "         quantity  of  daily  dose  of  .         .         . 

"  "         routine  method  of  drinking,  at  the  resorts 

"  "        Silesian,  atomized,  for  laryngeal  catarrh 

"  "         temperature  of,  for  drinking . 

"  "         time  of  administration  of        ...         .         114, 

"  "         varieties  of,  vide  above,  classes. 

Webber's  classification  of  climates 
Weiss  on  the  physiological  effects  of  calomel 
Wermel's  observations  regarding  cholera  . 


87,  88, 
109,  110, 


113, 
111 
109, 


90 
302 
372 

92 
110 
113 
115 

87 

344 
345 

343 
346 
344 
117 
116 
112 
333 
338 
339 
339 
339 
339 
339 
338 
335 
336 
335 
336 
90 
107 
108 
111 
107 
110 
112 
114 
-113 
110 
279 
115 
115 

299 
409 
361 


—  487 


Wiesbaden,  a  German  watering-place 
Winds,  importance  of,  vide  Climatotherapy. 

Wine  in  cardiac  debility 

in  diarrhoea 

■'      as  a  causative  agency  in  bypertrophic  biliary 
Women,  diseases  of,  Franzensbad-Moorbader  in 


Yalta,  a  health  resort  in  the  Crimea 
Yessentucki,  chemical  composition  of 

"  compared  with  Ems 

"  "      Vichy 

"  contraindication  to  use  of 

"  dosage  of 

"  indications  for  use  of 

"  in  atonic  gout 

•'  temperature  of 

Ztemssen  on  calomel  in  cholera 
Zittmann's  decoction  in  syphilis 


PAGE 

344 

43 

43 

cirrhosis 

426 

345,  346 

313 

93 

96 

105,  106 

96 

111,  112 

105,  106 

222,  228 

116 

376 

438 

'■^yoi  1  '/  uj 


